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05080278CITY OF CUPERTINO BUILDING DIVISION PERMIT CQNTRACT.nRA ''ORMA'TIUNs,1:, 7e;t9 XS� �� s. _ _~YRYtib*4�� t Yti.;d+Y6x3�9f ,.&Fd °'S •:, B UILDING ADDRESS: SUNSET ROOFING PERM7NG05080278 OWNER'S NAME: RONALD & PATRICIA CLARK 817 MODESTC) ST PERMIT ISSUE DATE ng/-ii/qn05 ONE: SANITARY NO. CONTROL NO. (800)513-2575 ARCHnEC AENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 bemby affirm that I Am licensed under provisions of Chapur 9 (commencing with Section 7010) of Division Sof Me Bounty and Proksmats Code. and my license is manforceandet(ec !! yR ,4!571 3 REROOF-T/O SHAKE, INSTALL COMP. SHINGLES D%WLlecoClue come Dau Con DELL AR CHIT EC TS DECLARATION 1 understand my pity alull bo need u public records {%((�� f} IZp. lY �ry art,y�ea.c� G Etr •� tt FtJ h Licensed Professional OWNER -BUILDER DECLARATION I hereby Affirm that I em exempt from rite Comeaclofs License law for the p V sa�� fallowing reason. (Section 7131.5, BuaneSa and Professions Cade: My city or county it L which mquime a permit to construct, alar. improve, demolish, or mpair any structure prior m its issuance. also requires he applicant (crouch permit to Ne a signed suumcm Met be As licensed in the of the Conummes luxus Law (Chapter 9 Sq. Ft. Floor AreaUJ -• Valuation pursuant provisions, (• A 6 A 4C100oo (commencing with Section 7M)of Division 3 of the Business and Professions Cade) or h that he is exempt memfmm and the basis for Ons alleged exemption. Any vialadan of i ;l}' arr.vY Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number •ccupancy Type net mom don Oro hundred dollars (SSW1. ❑ t, As owner of the property or my employees with wage as their sou compensation. Required Inspections will do the work and meavueme is not intended or offered for sae(See. 7044, Business and Professions Code, The CantmeSoes Lt. taw does rot apply So an owner or 9 P Property who builds ar impoves Merton, and who does such work huvaf or through his awn employees, provided that such improvements an, notimmnded ora@sed ferule. If. however, the building or improvement is Sold within one year of completion. the owner. builder will have Me bout of proving dist he did Out build or Improve for purpose of sole.). ❑ 1. AS Or of Me property, Am exclusively contracting with licensed cowmeme, So construct Me project (Sec. 7004. Business and Profesdom Code:) The Conuumm's I.J. man taw does not apply AS an owner of property "a Wilds or improves memos. and, who coned for such projects with a contrasmr(s) licensed pursuant to the Con cremes License law. ❑ IAmuenptunder Sec ,B&PCfx Mismuon Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under pwlty of perjury ore of the following dmlandons: I hsveand will maintains Ocri ficam of Cauent in selGinsum ("Wenches Compen- ssdw. as provided for by Section 3700 of the Labor Code. far Me performence of Me work for which this permit is issued. ❑ I have and Will maintain Workces Compensation Insurance, as required by Section 3700 of the Labor Code. for the performance of the work for which this pewit is issued. My WorkSagoropenest Insurance comer and Polity number are: Cancer: 1Nl- Poliry No.; CERTIFICATE OF EKE APnON FROM WORKERS' - COMPENSATION INSURANCE (Th4 s=box need notbecompleted If the permit is foronc hundred dollen (SI W) mlesa) I cenify Mat in the perfornamx of the work for which this Permit is issued, I shal not employ any person In any mannerse AS b become Subject rode Workers Compensation ".of California. Dam Applicant NOTICE TO APPLICANT: If. after making this CeAOnm of Exemption, you should become subject So me Worker's Compensadon provisions of the Labor Code, you must foMwith comply with such provisions or Nis permit shat be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that Mere ins comwctinn lending aprey forthe Performance of the work for which this pewit is issued (Sec. 3W7, Civ. C.) laedeh Name , Lunde,`, Address I «mfy, that I have reod this application and sum mat the above information is correct. I agree in comply with all city and county ordinances and sum laws relating So building conswction• and hereby authorim rtpretenu0ws of this city So sour upon me ahovementioned property for inspection purpawa (We) agree to Save, indemnify and keep humleu the City of Cupertino against Ilabilides, judgmenu.eow and expenses which may in my soy accrue gaup said City in consequence of the grouting of this pewit. APPLICANT UNDERSTANDS ANP WILL COMPLY WITH ALL NON- DINT Issued by: Date SOURC • GUL S. Re -roofs Type of Roof nature of APpllesnt/Ca our au HA DOUS MATERIALS DISCLOSURE Will me aPpImm rfuture Wilding =upset aero or handle havmdon materia AS defined by the Cope sirs Municipal Code. Chapmr 9.11• and Me Health and Safety Code, Emma 25532(a)7 p All roofs shall be inspected prior to any roofing material being installed. ❑Yes ¢A6 If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding occupant use equipment or devices which It havamou airconumin nun den by Me Day Ama Air Qualty Management all new materials for inspection. strict? ❑Yes u I have mel the huardmn.=,let, tequiremems under Chapmr 6.93 of the Califon nu Heal BSaletyCo&d Savom25505.25533w25534.lun&rnvutWifmo Wilding Mannot currently hove a meant. that it Is my repo hilily 0 mildly Ma Occupant of Me mqui w UAL Wm or in aCemficamafoccupancy, Signature of Applicant Date All roof coverings to be Class "B" or better 0 o m agent Oam S i/ L. e �� 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 Roofings'vlV� T A40010:�- Septic Tank Sheet Metal Sheet Rock e �� 0 CUPERTINO CITY OF CUPERTINO "ROOF PERMIT APPLICATION FORM APN # / 1 0 S Bldg Permit Fees Date: ®Sr— Building Address: Energy U p Owner's N e: O � � Phone, Co tractor: Phone # C9 Jl9 ET License #: Z S/ Co tact Phone #: Cupertino Business License #: BUSLIC Type of Roof Covering: Existing: Proposed: ❑ Built -Up Roof ❑ Asphalt Shingles ❑ Built -Up roof T j>F � Asphalt Shingles 4485 /%'I 'X�Wood Shakes L�, ❑ Wood Shakes T ❑ Wood Shingles rU ❑ Wood Shingles Other (Specify) A->dv ❑ Other (Specify) Nyi�her of existing covering To be Removed ❑ Provide I.C.B.O. Report # ❑ Provide Mfgr. Installation Specs. S� I Have Read, Understand and Will Comply Wi Cu ertino's Tear Off Policy: Job Description: EYhOVE cS 9tEE pLYluool7 ;4NEL5 m /N5rT1t1L �, z"CVCtl — o Tt a 4 Co Residential Commercial ❑ Fire Zone: Yes ❑ No Confirmed with Planning Det. if there are any restrictions: LJ Cost of Project: Type of Construction: Occupancy group: Qty. if Annlicable Fee ID Fee Descrintion Fee Grown 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 ii_