05050119 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 3 CONTRAGTOR,INFORMATION 9;
BUILDING ADDRESS: WINTER ROOFING INC PEaMITNGb 5050119
OWNER'S NAME: FERMrTL6UEDATE
/2005
ONE: SANITARY O. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
ZOo LICENSED CONTRACTOR'S DECLARATION lob Description
x F 1 belvby affirm that I am liceved under previsions of Chapter 9(commencing p
U. with Section Division 3 of do,Business and profesiimu Code.and my became is FI
in full forte andforte and cf �u )1�
? ED
LimaeClass `� Lice �raa�� REROOF W/COMP. SHINGLES
'rp Do ConOacor
ARCHITECTS DECLARATION
W 1 understand u reco
anJ my plana shall W used public rds
u '� )�_
''LL Licensed Pofessionel / 2005
.OS OWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt firm the Contractor's License Law for the
pO following mason.(Section](1313,Business and Profcmcinns Code:Anycity or county
ym rL which requires a permit to construct,alter,improve,demolish.or repair MY Stmeam
msprior In its issuance.also requires the applicant for such Permit u file a signed satemens
Ihas he is licensed pursmnt In the provisions of Ne Contractor's License Law(Chapter 9 Sq. Ft. Floor Area U
'FC (commencing with Section1000)of Division 3 of the Business and Professions Cak)or
i $
that M is exempt therefrom and de,basis for the alleged exemption.Any violation of
Section]031.5 by airy applicant far•permit subjects su applicant to a civil penalty of
her 3 �I erpp Occupancy Type
more than five hundred dollars(5500).
❑I.as owner of the property or my employees with wages sa their role compcnation,
will do Ne work,and the structure is not intended or offered for sale(Sec.Told,Business
and Professions Code:The Contractors Liceme law does not apply to an ower or Required Inspections
property who builds or improve themon.end who doessuch work himself ortluuugh his
own employers,provided does such improvements arc not intended or offered formic.If.
however,the building or improvement is sold within ane year ofeomplction.the owner-
builder will have Nc burden of proving that he did not Wild or improve for purpose of
sale.).
C)h as owner of the pmpeny,em exclusively contracting with licensed mnuacors to
consumer the project(Sec.]oda,Business and professions Code:)The Contractor's Lt.
ase Law docs not apply in an owner of property who Wilda or impravet thrombi,and
who contracts for such projects with a conovaor(b)licensed pursuant o the Canvatora
License law.
❑I am exempt under Sec. ,B&P C for this reasons
Owner Data
/j WORKER'S COMPENSATION DECLARATION
-` 1 hereby affirm under penalty of perjury one of the following declarations:
1 have ane will maintain a Certificate of Coasent to self-insum for WorkersCompen-
soien,asprovided for by Section 37W of the Labor Code.for the performance of the -
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,az acquired by Section
]00 of NC Labor Code,for to performance of the work for which this permit is issued.
My Workers C mrematia su rem,carrier and Policy number art:
Carie, Policy No.:
CERTI ICATE OF EXEMPTION FROM WORK, S'
COMPENSATION INSURANCE
rlTusi pion..it not W completed ifib,permit is(orae hundred dellue($108)
loss.)
1 certify Nat In the performamc of the work for which this permit is issued,I shall not
employ any person in any manner sou in Wcome subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CcniOcam of Exemption,you shun lJ
become subject to the Worker's Compensation provisions of the labor Code.You most
.J0 forthwith comply with such provisions or this Permit Mall be deemed revoked. .
z CONSTRUCTION LENDING AGENCY
I hereby afltrm that there is a construction lending agency lnr the performance of
(Y 0m work fur which Nis permit is issued(See.307(,Civ.C.)
II]z Lender's Name
z Lcndcr's Address '
U
U Q 1 ttnme docs I ply read this application and sate Nes the above information
ng to ,
(1.l" corrett 1 agree o comply with all city and county ordinances and sole laws relating e
0U aWildingovconaued property
hereby imosedarix¢pmsenutiw of this city mantas upon lM1C
r� aWvemcntinnetl propenY for inspection purpecs
gy
(We)a tee ho save,indemmfy and keep M1umless the City of Cupertino against
r('n liabilitmaj mcnu,cosu and expenses whichmayinanyweyeccrucagmen,said Ctry
U z APPnx ccof Oc rs this rmit.
IA UNDERST
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO C REGULATI
Re-roofs
choig rc of D rq. ORDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or forum building occupant store or handle Intuitions material
Tined by Nc Cupenieo Municipal Code.Curler 9.12,and the Health and Safety
We.Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑YG
Will the applicant or furore building occupant use equipment or devices which If roof is installed without first obtaining an inspection,I agree to remove
it h mneous air contaminants cfined by the Bay Area Air Quality Management all ne statists for insp tion.
'rens?
C]Yes
ON.
I have neW the havardnus orielsrcyuircmenu under Chapwr695 alike Califor- .-
niaHca &Safety Code,Sectio 25505.25533and 25531.1undersuntl that Wilding
docs t'Lomedy haw a that it is my rcapontihilily les nastily the aeupant of Nc �7 Oat
it cnk,whc n etpoor to smarm ofaCcrllfican,OfomIgancy. / i a ug o f A Weant Date
o da ereI. rizenI Date All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
C2S ' , /!
OWNER'S NAME: ao PHONE #
GENERAL CONTRACTOR. FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontra rs and complete the following information:
60 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
�_ REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Ad ress.
za an
Owner's Name: Phone#:
Contractor: Phone#: License :
Contact: Phone#: Cupertino Business License #:
� nr
i
ype of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ ilt-Up roof
[]..,Asphalt Shingles e Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Nuryber 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: 0—
Job Description:
Oe
Residential Commercial ❑
Fire Zone: Yes ❑ No ®— Confirmed with Planning Dept. if
there are any restrictions: U
Cost of Project: Type of Construction: Occupancy group:
d
Qty. if
Applicable Fee lD 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
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