05120007 CITY OF CUPERTINO T�.,� a
BUILDING DIVISION PERMIT
BUILDING ADDRESS: WOODS ROOFING Pm""OS120007
I10366 AVENIDA LN
1 OWNERS NAME: PERMIT L$UE DATE
1 MYRNA YITZCHAK (HOUSE) 2179 STON
NE SANITARY NO. CONTROL NO.
(831) 637-5576
ARCHITECDFNCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i UCENSED CONTRACTORS DECLARATION lob Description
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auby"M s 1 lived enaer prmlvvu d Chp 9(inn tae{
tJ �Ihy aon7a l°f DiWbn 3&f Bmnm rna Pld..i u C°ae..na my Ban¢I.
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-5/31 REROOF--T/O SHAKE, ADD GERARD STEEL TILE
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W ARCHm=DECIANAITON
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OWNER-BUILDER Ik CorT o
7r I hemby.Rasa Wu I am eaempl I.We Cmuands Lima¢In f«i(C
2 p o folloainp Icasay.(srsa n 7031-5,B-s—anal Prakssae C^de:My&Y m moray
ISE Mich Mquim a pumit In mnnnbL sic;tnpmw,demwNa«"Pair any w,aty°rt 28000
zy iniorw uimmrcc.rtID rmWrc the wNbm rm w permit W fh a si{rcd suWmvu
—� ihu he hlkcmd paIDanity We pmvisom d de Cani w's Liaml (Ch,ptm9 Sq.Ft. Floor Area Valuation
a�9 (mmmencin{wiW swim7000)d Dlvi.lm J dike Brdnms ari Prdmlau Coae)«
e3— Wa 4 e du,rapi there.and the buds for the speed w��rLap�d'm My A."d
Sccdm 7031.5 by any appB f«a Pamh as ta)c me.ppllcmt W a CIA P-"Y Of AMr Occupancy Type
ms more dun nw baaamd orris(SSBBR
❑Lu owner or i p°paey.amy=1anym wan va{n u Iheh sale mmprn.adw
'nud ft %!,,.°'Roam uran"med`d«°B°ed Ws (srtmu.B."_ Required Inspections
sad Pratug m Code The C®tea I—Ir doe m apply b w 9 d q p _
properry vM wild,
iym«impn.v Wamo,andwho alas vomit araff «W°°{hh. �r
mw emp)aas Wa a&"i pmnd lmpr an4,1 hire na I=Of a anL fa Ne B, (/y//C//—L
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w®n apmmr, urr Within am Ira dmm Wthe amu
hulWm wW hue Ih[huden d po•iat uw k ma.«MW a impmw r«pulpa¢d
ale).
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evnat La de project(sec.n an Basals ad Pw( wi Carla)The Cmu..Li-
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WORKERS COMPENSATION DECLARATION
I bemby affirm male'pmaby a P jury.a Wv f°IbMo{
hwaM w0l mainai°aCeNDaedCamemW mB-lasum r«w«4racmapcn- .
„pmvidd fw by Secavn 7700 d the Loh«Coda fa de per/amula d the
wit r«.hfm W a pcnil u i,avM
❑1 hw and will m mud,wartces ccnP-Ladm Iluunme.u ngaaed by st tion
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Cartier. • T°"� PNY 'C9—�µ'I�
CERTIFCATEOF EXEMPTION FROM WORKEAS
COMPENSATIONINSURANCE
(The calm meal embemlvplcetl Bthe pvmi a f«mc hmOW a°Ban RIIMB
«less)
1aNfyny M the many read We wartf«.lick Wspewita"'Cn 1.IWIas
empty CaaUorml i DaX ora°aerIDabbccmoa sabjmlW WO WaAva'Compemulov .
1Jra d CLIfoMa Due
NOTICE
NOrICE Tbj W tbL NT:If,meta ri n p D. ofd Eacn co You mm
nuld
(.comesabjeety iawatch Com,.ana praWd°nl of We IAhor Code.Yin man
.Jz f«IhwiW mmplY rill such lvv.isms«Wi+pemtilshall Ee daloed"Ned
Z'O CONSTRUC ION LENDING AGENCY
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a > We wat f«whk aria pmndl awa (SM NM,Civ.Q
pLrn ds Name
= z Isa4r.Adma
UC) I anify WWe
Wal I baw read aPPLM.and mac dirt We above id9rnlasm e
Ly E c°nmt 1 arts W.amply w all city andou
cmy°di aval.tan pis mlasnt W
Owad.{eaurmrim.Q bmeby aaLwdr,mpmmnwiwaafoa,k,Wemnupm We
LIa abo -men land poppy for Iaspemn,Pug=&
y (Wc)app W sam m mmfy and lup bumlos the Cay ofCupmim apin l
H liabilbin,judtx^a.e°m a,i penia whip may la my way a m¢noun a aid City
U in corta9mme Of We trmHntd ae pmmil.
APPLICANT UNDERSTANDS AND WILL COALY WITH ALL NOWPOINT Issued by: Date _ f
SOURCER 0
yz�i�vS Re-roofs JT-bm
Si{aavrc of
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wm Weglp0ontafulum Wu 90=Wad'r ah 4u.aaamamdal
If
defileL by We Cupmim Maospal Cade,Cbapa 9.11 oral We HmM 11h aSafmy
.Savin 85J1(gT Clm� All roofs shall be inspected prior to any roofing material being installed.
❑Ym
Will ft.,aanr a rune bdldin{.,m usa eq°ipm,or devima Mien If a roof is installed without first obtaining an inspection,I agree to remove
emit hvadms sr cmumtrwas as dcBled by the Bay Mu Air QWily Mana{cmcm all new materials for inspection.
DevkR 1 _
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1 haw mtl the h>ardous vuWdae Iequn—under CTupu 6.95 dale cwnr.
N HolWdr Safny Coda,Srcvveu505.m33 dU534.IwdmtadW ffW bLnldint
dm ria cmuulY haw•mw.ihu it v mY mapms(ililY W^udrY ibe ea Nal d due
mg°aclmw Mich b.mnpda oracc,01a 01/0" °"�'� Signature of Applicant Date
-;ti ` ` �'45 All roof coverings to be Class"S"or better
orller« ,rd, Dun. .
CITY OF CUPERTINO
Son REROOF 0S`112
CUPEkTiNO PERMIT APPLICATION FORM
APN# 3 1/ Z _ 4! S — � 3 O Date: / ' /
y d I l u_S
Building Address:
/d3 � � Com' ,�•" w - -
Owner's Name: Phone#:
�. 1, -01 33
Contractor: lf Phone#: License#: -5
( s
/d S, o ' L3
Contact: Phone#: Cupertino Business License#:
zvFr/ o
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
>ir Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) X Other(Specify) St c—P "rZt .
Number of existing coverings ,V� Provide I.C.B.O. Report# Gs 2—F`E'Y
❑ To be Removed 'IAC Provide Mfgr.Installation Specs.
AOL I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:/
Tim .�� a.✓o/�� �-, _. sz� %. - CPQ .9 „ 5 11241,
Residential ` Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D_pt. if
there are any restrictions: LJ
Cost of 8'pproject: o Type of Construction: Occupancy group:
2 , ODS
Qty. if
Applicable Fee ID Fee Description' Fee Group
/ BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING