06060103 CITY OF CUPERTINO 74_55W___ ' '
I BUILD�NGDIVISION _RA_
TION'
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BUILDING ADDRESS: AFFORDABLE ROOFING PERMIT"o.06060103
''2690 ALCALDE RD
R'$NAME: PERMIT LSUE DATE
ANDERSON THOMAS P AND DORISV1910 DAY RD. 0
PHONE: SANITARY NO. CONTROL NO.
(408) 842-7100
ARCHITECT/ENGINEBUILDING PEWMINFO
ER
BLDG ELECT PLUMB MECH
a C LICENSED CONTRACTORS DECLARATION lob Descrir� A ®®®
i I bacbY amrm WIa 1 m Ikcved oder P.11M of Clupux tt(comm—
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OWNER-BUILDER DECLARATION
.�mC I hereby,mrm m 11. aempt from the Canuanda Lkn y y f«Ile
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ss< dw be b,licnnaad p..m ft p LiouaNe COnu 's Llmnm lur(Ctaapmr9 Sq.Ft. Floor Area Valuation
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Swim 7071_5 by a,,y appllom fa a pumit aobJem the ant m a CMI paalty Or r Occupancy Type
twt mart duo fiw hlWred dawn WWI-
0 1,u owe Of Itis pmµaay,a my mnpbym with va{n u Nc'a mk e«Openntaon,
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oda cctd cowmen m mese d«n am r« .eesQ.7a.,Bed Required Inspections
ab Paofesaimu che C®u,cmr's Llanse t...dos not spgh W m awma a of q Pe
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rhe wnuaaa(«a MjJ riN a cmuxwAs)I'ua,wd Na male funuamah
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WORREib'S COMPENSAMW DECLARATION
�. Ibaeby af�m,oder pealty of pct'Om Or de fdkwn{&du&dmv
14.e and win mdnuie a Ceniflae of Comm,to EDB Inwrt fa Wo,�f,Camprn-
utlm,u Prmided far by Semi«,77,]0 a dhe Lab«COde,fm U Nrf«mmm of Ibe
wmt I.rnkb tarts pvmk is iaataN.
1 boas aM rill mains io Wortefs ampamtian lumares,u re imd by section .
17000r Ne Labs Code,r«NO pmfamure OTNe wart far wikn WTI permit Is"0"
My Wor .COmpevutim IIIIIG:aRlQ and POUcy numbs n:
a ae_ j 1ty{P Proxy Na,✓7?� '�
F1 OF MON FROM WORICIERS
COMPENSATION INSURANCE
(ibis malas rcN wt bOcomp•...•B th Ix ftbr«om lbm doom(5100)
Or
1 certify Nat u Ibe MI..Of Iva rah lar rhkh Nu permll k lamed.I sha0 cot
cmPloy any prnan in any vturermu mbccomc Ob)=m NC Warted Cootpcuulo
IED of alifamit Due
NOTICE TO APPLICANT:If.,Mr m W Og NI,CatiOate N EaanptkO,yo aboubl
become mbjm m the WO j Cmt(s+ dm pmrtiou a t4 rah«Code,yin mw
,JO rmW tb WMply wN inch Pmv(xMms a NU P 11. I be dcmncd mmtcd.
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CONSUCITON LElDDIG AGENCY
1-+ 1 hacby affum Itiu Nero i„conumaim Wdin{,{ency I.ttr Pcrfamures a
q' ve wort f«rhkn Nla permit ti iseed ISOs 1091.CW.C7
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z Lcndces Addm4s
U O 1 catiry W,t 1 h red W.applkatim and sum taut Nc aboas IId«ma1M,n is
U.F comm l,{rtem apply wN dl city and co,mty o Inan«s aM uaae laws Miami
OU WJdiuS cwutneaon,W Mtby,aN«be rtyrt. ,.tins Or Nis cirymcvcr ePm Ne
r Fs7 abuts OoOi paprny r«impcctim Pu '
(WO),{t¢to sass,iM nifY aced k ,p harmlea tk city of cupmfm a{dtut
F' Li Uam JW ..cum@Ottt. nma rhicb may In my ray amm,{almt,dd City
U z i.,., of thO ll a o{of thi.p n k
^ APPLICANT UNDERSTAND AND W COMPLY Wmi ALL NON-POINT Issued by: Date GL
SOURLATI S, r
�f G� • v /"� Re-roofs
Si{nuwe arAPp{ RAZ&�S MATFRIAI DISCLOSURE Type of Roof
OWI0 Nc applicant«fuwrt bwlbin{orcepmtmm«bartAc bmrdem rnsmAd
ltnted by I-Cnpemw MankiP•I Code.Cbpty 9.13.sad Ih Ha1N aatd Sdeq
.Seaim 3lsnU)] All roofs shall be inspected prior to any roofing material being installed.
❑Yn ❑Na
wu Ne applau«rauvc dwdn{«mwm am 9wPnm « wbk If a roof is installed without first obtaining an inspection,I agree to remove
•:mit lurardntu dr..I .,..u&ftOcd by Ne Bay Am,Ala Q allty Maa{cmcd all new materials for inspection.
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Ou HOIN h SdaYCade.Scctiao]3503.35771 ma1255J4.1 urdcmaod Ilu If Nc htilWn{
dos cot mnemh nuc,con.,. thu It v mr rtapOodNlkr n tutirr Ne asupant of tle
"gat. whkn Prwr af.ce,tieamaro�,�mer/ Signature of Applicant Date
� / a All roof coverings to be Class "B"or better
timer a wmaria<d,{ent Doc
Community Development
10300 Torre Avenue
J'a" . Cupertino CA 95014
Telephone(408)777-3228
Fax(408) 777-3333
,MkTINO
Building De artment
JOB ADDRESS: v
PERMIT #
OWNER'S NAME: VYr PHONE # gO el p p
GENERAL CONTRACTOR oc 6FAX #
I am not using any subcontractors: D
Signature Date
Please check applicable subcontractors and complete the followinginformation '
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring. Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34244018.00
DATE ISSUED. . . . . . . : 06/13/2006
RECEIPT #. . . . . . . . . : 34828
REFERENCE ID # . . . : 06060103
SITE ADDRESS . . . . . : 22690 ALCALDE RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ANDERSON THOMAS P AND DORIS V
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3977
RECEIVED FROM .. . . . : AFFORDABLE ROOFING
CONTRACTOR . . . . . . . : RICHARD GARCIA LIC # 24428
COMPANY . . . . . . . . . . AFFORDABLE ROOFING
ADDRESS . . . . . . . . . . : 1910 DAY RD.
CITY/STATE/ZIP . . . : GILROY, CA 95020 _
• TELEPHONE -. . . ..: (408) 842-7100 "" -
FEE ID UNIT QUANTITY AMOUNT PD-TO-.DT - THIS, REC NEW BAL _
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 14, 000.00 212 .76 0.00 212.76 _ . . 0.00 .. .
BSEISMICRE VALUATION 14, 000.00 1.40 0.00 1.40 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 214 .16 0.00 214.16 0.00
METHOD OF PAYMENT AMOUNT NUMBER
OTHER 214.16 AMEX
TOTAL RECEIPT 214 .16
VV4
• C !TY OF CUPERTINO
REROOF Q/pj
CUPn,-1Na IPERiV I T APPLICATION FORM
APN# Date:
3y -uhf arg
Building Address:^�
Owner's Narne:
Contractor.
Contact: s Cup trio Bu: rtes License #:
Type of Roof Covering:
Euisthig: Proposed:
❑ Bui!t-Up Roof 0 Built-Up roof
0 Asphalt ShinglesAsphalt Shingles
P; Wood Shakes ❑ Wood Shakes
Wood Shingles ❑ Wood Shingles
❑ Othw(Specify) ❑ Orher(Specifp)
Numbs of existing coccringvl- . .. _._,.. O Prcvido LC.H.O.Report N _
Q To be Removed I ❑ Provide Mfgr.Installation .pets. __
I Have Read Undcrsutnd and Will Cor with Cr 'lupetinos Tear Off Policy:
Job Description: 1 // —`
L ?� J EPQ
Residential Corr rierctaY ❑ (� ��
Fire Zone: Yes ElNo p CJ Confirmed wi: i Planning gp
I there are any r :striedons: Cl
Cost ofProject: — 7.) ;of Construction: Occupancy gr. up:
Qty. if
Applicable Fee ID Fee Description_ Fee Gro_u
BPERMFEE BldgPermit Fees BUILDING
BENERGY Ener BUELD LNG
BSEISMICRE Seismic Fee Res BUILDING
BSEISNELCOM _ Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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