06100042 CITY OF CUPERTINO CdaITIGTOR IN �RMATI�JN�
BUILDING DIVISION PERMIT
.
BUILDING ADDRESS: COSMOS ROOFING PERMIT No.06100042
6045 BOLLINGER RD PERMrr ISSUE DATE
OWNER'S NAME:
ANVICK SCOTT E AND JANET G 1901 OLD MIDDLEFIE10/06/2006
SANITARY NO. CONTROL NO.
INE:
(650) 969-7663
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB ?AFCH
a o a a
o p LICENSED CONTRACTOR'S DECLARATION Job Description
ty 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
>>y in itis trice and effect 3 Lic 5 / REROOF-T/O TAR & GRAVEL ADD NEW TAR & GRAVEL
j ? License Clan C�
ARCH 1N iF
Z 0 1 understand my plans shall be used as public records
�yU
yO H Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5.Business and Professions Code:Any city or county $8460
e which requires a permit to construct,alter,improve,demolish,or repair any structure
Z r prior tit its issuance.also requires the applicant for such permit to rile a signed statement S Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
uF=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L .» that he is exempt therefrom and the basis for the alleged exemption.Any violation of OType
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or F Occupancy y yP
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is notintended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs 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 completion,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 Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance or 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'smpensation Insurance carrier and Policy number are:
Cartier. �' +-0(— Policy No.:571'':�00/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(('Itis section need not be completed it the permit is for one 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
Laws 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 Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
F�.t ter I hereby affirm that there is a conswction lending agency for the performance of
ai > the work for which this permit is issued(Sec.3097,Civ.C.)
(S7 QLender's Name
a z Lender's Address
I certify that I have read this application and state that the above information is
O correct.1 agree to comply with all city and county ordinances and state laws relating to
U building construction.and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments, osis and expenses which may in any way accrue against said City
V Z in consequence or, granting of is Date
t APPLIC ERST D ILL CO 4i Y WITH ALL NON-POINT Issued by:
SOURCE
�64 1 d ( Re-roofs
Signature of Applicant/Contractor Dam Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future 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 roofs shall be inspected prior to any roofing material being installed.
❑Yes dl
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes (j}Nrf
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty C ,Sections 25505.25533 and 25534.1 understand that if the building 1/ 17 v
does not currcntl a tenant at i rcsponsi 'ity to noury the occupant of the
requircm is muses/ run uanccor cruficatsoftxcup / Signature of Applicant Date
a fid`'l 0 6 All roof coverings to be Class"B"or better
Owner or authorized agent Date
CITY OF CUPERTINO
1 1 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37538004.00
DATE ISSUED. . . . . . . : 10/06/2006
RECEIPT #. . . . . . . . . 36338
REFERENCE ID # . . . : 06100042
SITE ADDRESS . . . . . : 6045 BOLLINGER RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ANVICK SCOTT E AND JANET G
ADDRESS
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4629
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : COSMOS, RICHARD LIC # 18844
COMPANY COSMOS ROOFING
ADDRESS . . . . . . . . . . : 1901 OLD MIDDLEFIELD WY
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94043
TELEPHONE . . . . . . . . : (650) 969-7663
.cEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 9, 000.00 158.76 0.00 158.76 0.00
BSEISMICRE VALUATION 9, 000.00 0.90 0.00 0.90 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 159.66 0.00 159.66 0.00
@9/29/2096 14:25 7075297663 FERMIT SERVICES INC FADE 02
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tures
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9UOCONTRACTOR BUSVSS DAME BvsDMSS LICENSE#
Cabinets&Millwork
cement @misting
Bacbri vI
Ewmvation
Ferming
l�loc�ng:
Lhwk.um/Woad
Glass/Glazing
Ynwlatio�
Omamental Sheet Metal
Painting/Watipaper
Pav
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s�pet Tank
M�
Sheet Rock
crtttactor sips&= Date
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CITY OF CUPERTINO
REROOF
CITYOf
CUPEkTINO PERMIT APPLICATION FORM
APN# , 3 f L?r, �/ Date: / 0/1,
Building Address: O qs `_t-� (_'
Owner's Name: � _ Phone#:
X66 - 74 � - 7� G3
Contractor: License#:
1FFS
Contact: Cupertino Business Lic nse #:
Type of Roof Covering:
Existing: Proposed:
Built-Up Roof - Built-Up roof
{� Asphalt Shingles ❑ 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 Cu ertino's Tear Off Policy:
Job Descripti
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LJ
Cost ofProject: Type of Construction: Occupancy group:
L g4160 UD
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