05060094 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION•
BUILDING ADDRESS: BLAIR ROOFING PERMITN 05060094
7558 ERIN W
OWNER'S NAME: PERMIT ISSUE DATE
DIANA YANG 1664 CROSS WAY Q6/14/2005
IF ONE: SANITARY NO. CONTROL N0.
(408) 295-6557
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOo LICENSED CON'TRACTOR'S DECLARATION O O O O
:ug w I hereby affirm Nat 1 am liconud under previsions of Chapter 9(commencing Job Description
Sz it Section]OW)or Division 3 Otte Busing sand Professions Code.and my license is
rad in11I.Oa and off -� , REROOF W/COMP.
j vOjr? Lieenu CI Lie.a
rp Dare 14 11.1,L TS DECLARATION a'LG n
ARCHITECTS DECLARATIO If
¢ 1 understand my plans shell be used as public records
3 Liccnud Professional
g OWNER-BUILDER DECLARATION
.�<q 1 hereby alri m Nal I am exempt from to Conum
acrs License Law for the
p 0 following mason(Secdon 7031.5,Business and Professions Code:Any city or ounty
K m which requires a permit to construct,alu r,improve,demolish,or repair any structure
$7000
y¢i prior to its issuance.also requires the applicant for such permit to file a signed statement
that the he is licensed pursuanuo Ne provision of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Ll U ij ,Valuation
LF$ (commencing wilt Section 70M)of Division 3 of Ne Businessand PmfcssinnsCade)or I�'f /,'�11�\1'��
unit he u exempt therefrom and The buts for Ne alleged exemption.Any violation of J L�L'�
Section 7031.3 by any applicant for a permit subjects Ne applicant to a civil penalty of
nm mem Nan ftw hundred doll+ta(OMC a. Occupancy Type
❑1,az owner of the property,or my employees with wages as their sole compensation,
will do the work,and me Itsuctom is not imenxd or offered for sale(Sec.]oaa,Business
and Profesamna Code:The Crnuxctofs Licence,Low does oat apply m an owner of Required Inspections
pmpony who builds erimproaes Nemrn,and who dmsauch workhimself or through her
ownemployces,providedmatsuchimprove entsarenminandedoroRemilforsale.IL
howavcr.mo building or improveme isso wiNinoneyearofemopledonteownae
builder will have the burce of oovi It. he did not build as improve for puryos of
talc.).
❑h as owner of the pro ray, a but elyco
it licensed conNaators to
construct the project(Sec. pfd, and essions Carl The Contractor'sLi-
cmue law docs not apply to an owner of roperty who Milds or improve thereon.and
who eonmcts for such projects with a eo ractor(s)licensed pumuml to me Conuactoes
License law.
❑Iamexemp,muer Sce. ,B&PCfor Niamamn
Owner Date
WORKER'S COMPENSATION DECLARATION
J I hereby affirm under penalty of perjury one of the following declinations:
1 have and will maintain a Ccru ic+m of Consent to self-insuu for Worker's Con,cm
tattoo,az provided for by Secdon 7]00 of the labor Code,for The pemormana of d¢
work for which this permit is iuucd.
❑1 have and will maintain Workers Compensation Insurance,a required by Secdon
3700 of the labor Code,for to performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carticc Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not he completed!fine permit is(mane hundred dollars(51011)
or kss)
1 certify mat in to p onnome,of the work far which thia permit is issued,)shall not
employ any person in any snssto MeoTespbj`wi0Wm C ovation
Laws of Califoroia.Data f-I lam
Applicant --- -NOTICE TO APPLICANT:If.after making Nis Cenlficate of Exemption,you should
become subject to to Worker's Compensation previsions of the labor Code,you must
foMwit comply with such provisions or to Permit shall be domed mwked.
Z O CONSTRUCTION LENDING AGENCY
I hereby af@m Nm them is a construction lending F Y g+FemY For Ne performance of
ai
Or work for which Nis petrel,Is issued(Sec.JOY].Civ.C)
W Q Lenders Name
z Icndcri Address '
J O 1 coolly tat I haw mad this application and sum mat thc above information is
U. F correct.I agree to comply wit all city and county 9nlinames and sure laws relating in
C)U building concoction.and hereby adhorim mpmacnutives of this city to enter upon dK
Ftl aow-mentioned property for inspection purposes.
(We)agree to saw,indemnify and kap humless Ne City of Cupertino against
N liabilities,judgments,costs and rare.which mayor any way ace.against acid City
of the
U Z APPLI ANT UNDERSTAng ofNDS
AND WILL
Issued b Date '�r 7,(r
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT y;
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanVCepoem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne a Cupint or forum building C e.Chop,store at handle Hearst
and
as donned by the Cupertino Municipal Code.CTaprer 9.12,Ind the Health anJ Safmy
joiliCam, ScNYesenON.25533(a)] All roofs shall be inspected prior to any roofing material being installed.
❑
If a roof is installed without first obtaining an inspection,I agree to remove
Will Nc applicant or Future building occupant use equipment car devices which g
it hazardous air contaminant,as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
I hawkf1l NedvaN,mw2535,255uimme5534.I rdesook dwifNe holding
rias.1curSafetyow.Serimm, .1itimymad255Ja.1 understands occupant
Ofng
Jos ml currently haw a¢rant tat it is my respomihility m notify IM mcupml of The l.Q
mquiremene,which mum he mel prior to issumce of a Ccouni of Occupancy. Signature of Applicant Dale
Owner or+uNoriwd agent Dam All roof coverings to be Class "B" or better
A,
Community Development
10300 Torre Avenue
F"' Cupertino CA 95014
Telephone(408)777-3228
It coo,
Fax(408)777-3333
�UPEf�TINO
Building De artment
JOB ADDRESS: ` ' PERMTr# OrO n ° y
-1 i5 �Rtl� v...)(
OWNER'S NAME: D\o >J 4 PHONE # 'J 1 - lns Ali
RA1,C0NTRACTOR u FAX #
et� 0GINC> /
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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
Roofin
Septic Tank
Sheet Metal
Sheet Rock
Tile
("OIL <E o
Owner/Contractor Signature CJ Date
1 pM
(rlvbLv,�D ' `�
CITY OF CUPERTINO
(C. RIEROOF p S b 6 u
�CUPErRTINO PERMIT APPLICATION FORM
APN# 1v ` U Vq Date: (01 I
Building Address: -7656 E P l � w �U
Owner's Name: Phon #:
�g�
Contractor: r�I C � one #: 1� License #: y O3
Contact: i� t, Phone#: -Yl Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
o 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 Wil] Com ly With Cu ertino's Tear Off Policy:
Job Description:
e<e: sv-i(�,��s w�Tfl.t�c, v cam. S T
Residential Commercial F-1
Fire Zone: Yes ❑ No 2 Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: �o Type of Construction: Occupancy group: i
� orb � ooP Z/
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
-7, ?
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