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07080043 CITY OF CUPERTINO g�y��,q��+ Bg� BUILDING DIVISION PERMIT PERMIT NO. 513UILDIT .pP��sS:VICKSBURG DRSIMON S/�j AME:ERS JAMES H JR AND VICKI L 3 866 RF XWOOD SAN]TARY NO. CONTROL NO. (408) 5-1-9700 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB Mn Z LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Divia n 3 of the Business and ofcssiuns Code,and my license is T/0 (E) SHAKES, RESHEET OSB, 300B FELT, 50 YR .°° in full force and cfkcti. Z License Cl Lic•# COMP ContracE Date ARCHITECTS DECLARATION CLASS �� COLOR CHAROAL 23 SQS 1 understand my plans shall be used as public records U h Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the op� following reason.(Section 7031.5,Business and Professions Code:Any city or county Li which requires a permit to construct.alter.improve•demolish•or repair any structure Valuation y prior to ita issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area that he is licensed pursuant to the provisions of the Contractor s License Law(Chapter 9 q' $14113 $ OF (commencing with Section 7000)of Division 3 of the Business and Professions of that he is exempt therefrom and the basis for the alleged exemption-Any Occup anC T e Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6 910 0 0 8P R Number P y yp not more than five hundred dollars($500). 1,as owner of the property or my employees with wages as their sok compensation. Required Inspections will do the work.and the structure is not intended or offered for sale(Sec.7044.Business and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale if. however•the building or improvement is sold within one year of compktiw.the Owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 1,as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The CottttacWes U. cense Law docs not apply to an owner of property who builds or improves thereon.and. who contracts'for such projects with a contiactor(s)licensed pursuant to the Comractofs License Law" ,B&P C for this reason I am exempt under Sec OwnerDate - WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Workees Compen- .an,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 700 of the Labor Code•for the performance of the work for which this permit is issued. My Worker's Corrlpensau9ry Insurance carrier and Policy,numberare- J,41 6,Z Carrier �/C—'"'�Cl` Policy No.�� CERTIFICATE OP EXEMPTION FROM WORKERS* COMPENSATION INSURANCE (This section need not be completed if the permit is 1`017011c hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers•Compensation Taws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Codc,you must forthwith comply with such provisions or this permit shall be deemed revoked. C) CONSTRUCTION LENDING AGENCY .--i 1 hereby affirm that there is a construction lending agency for the performatec of i> the work for which this permit is issued(Sec.3097,Civ.C.) a Q Lender's Name Z Uendei s Address C) I certify that I have read this application and state that the above information is r. correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction.and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. ' (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against said City Zin consequence of the granting of this permit. Date APP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued l:y: SO EGULATIONS. J Re-roof 3 Signature of lican ontractor Dae Type of Roof RD MATERIALS DISCLOSURE yP Will the applican r uture building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? [All roo''s Shall be inspected prior to any roofing material being installed. 0 Yes If a too;is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which tit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. .)istrict? Yes I have read the hazyous materials requirements under Chapter 6.95 or the Califor- nia Health&SafetyCode,Sections 25505,25533 and25534-I understand thatif the building docs nLurmly havea tenant,that it is my responsibility b notify the occupant nC the Date requ' ich must mel prior to i trance of a Certificate of Occupar�yO Signature of Applicant All roof coverings to be Class"B"or better Owner or authoriz agen Date Community Development 10300 Torre Avenue k a` Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: 766hV,-,/-r ,,hL)r,g -D . PERMI1-7�U0Y�OWNER'S NAME: A-�,' S,-,bbi ve PHONE # yo-'-- GENERAL CONTRACTOR: FAX # CA V-6 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI:�TESS 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 ;.44,2 a,j Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date INVOICE INVOICE INVOICE INVOICE II4VOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO PERMIT INVOICE OPERATOR: CathyS Sec: Twp: Rng: Sub: Blk: Lot: APN 36310008.00 INVOICE DATE. . . . . . : 08/06/2007 REFERENCE ID # 07J80043 SITE ADDRESS 19766 VICKSBURG DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA OWNER GEERS JAMES H JR AND VICKI L ADDRESS 19766 VICKSBURG DR CITY/STATE/ZIP CUPERTINO, CA 95014 CONTRACTOR DARRYL SIMON LIC # 23053 COMPANY SIMON SAYS ROOFING ADDRESS . . . . . . . . . . : 3866 REXWOOD CT CITY/STATE/ZIP . . . : SALT JOSE, CA 95121 TELEPHONE . . . . . . . . : (408) 531-9700 FEE DESCRIPTION DUE FOR AMOUNT DUE PAID BALANCE ------------------ ---------------- -------- BLDG PERMIT FEES PRINTING PERMIT 223 .56 223 .56 0. 00 SEISMIC FEE RES PRINTING PERMIT. 1.50 1. 50 0.00 ---------- ---------- ---------- 225 .06 225. 06 0 .00 CITY OF CUPERTINO !Xi I REROOF CUPERTiNO PERMIT APPLICATION FORM APN# Date: � , �_ U � 3Gz� 16vo � . civ Building Address- 197,66 dd ess:976b 6 o T4 T, Owner's Name: Phone#: 6l�l 6 L S r�3 ��" u /08 -z�7 Contractor: License#: 5f- a m s �J il ✓` Contact: Cupertino Business License #: North fty Pe�� rye Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles >f Asphalt Shingles Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) Number of existing coverings ❑ Provide I.C.B.O.Report# ❑ To be Removed ❑ Provide Mfgr.Installation Specs. I Have Read,Understand and Will Comply With Cupertino's Tear Off Policy: Job Description: AAs s�eb /f S�Y C.1", �!�� !-� s3var o9 v Residential 9 Commercial ❑ 3 Sys Fire Zone: Yes ❑ No ❑-- Confirmed with Planning D�t. if there are any restrictions: Cost of Project: Type of Constniction: Occupancy u,� / /31 Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILDING BENERGY EnergyBUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING