00110058 CITY OF.CUPERTINO
Bull.Dwc DIVISION PERMIT CONTRACTOR INFORMATION:
`BUILDING ADJ)0270 SCENIC BLVD WESTERN REGION ROOF NG" '"G 00110056
°"'"''ks"NDA[13
: _VER STEPHEN T AND ELA NE L 231 N 121'1-1 ST nr1'LlcnrayNsu/1
1.]./13/c000
ANJ
IONF.: - - SANITARY NO. CONTROL NO.
(408)360-9111
O O O 1 ARCHITECT/ENGINEf!R: BUILDING PERMITINFO
pWWp BLDG ELECT PLUMB Mlicil
f t y
� �, LICENSF.DCONI'RACfOR'S UECLAkA1'IUN Job Description
0 Z'2 e I herchy alTrm that I am Iicemod under fnsivar ns of Chapter 9(commencing
F„tai ins«Ii:,nannruivi.inn3nnnel+a,ine..anJPnfe..mmc enandmYrcen. REROOF REMOVE 15BAKE. REROOF W/1/2 CDX
c m - i,m frill force and etfact. y Q 7 9%0
O O License Clan,_ /_(_ ].at,M
X t=s-1�-f 3�aq
m 3 or C, A ❑il'I ECI"S UECLAkA )N
C t=ON 3 1 undenomd my planI I he used o public errands
w s p'p Licensed Profe.nional
is S: z OWNER-BUILDER DECLARATION
R a I hereby affirm that 1 a exempt Bom the Contractor's License Law for the
F 2Ffallowing maaoa(Section 7UL5,Business and professions Code:Any city or county
F� whit 4 nit) , thr I heard st p -any a stun
pr
Cj� 'orl I 'Jsrrequire,thlie ,f hp- 'tt 'g L,t null
-- bar he t atrome I to the I' s fB C , t rat - La (Clapter9 Sq. Ft. Floor Area Valuation
0.bmnmocia,wim section Wild)al Div.tin.3 of,he Burnes,red Profession.Gala) g 18320
or thio he is exempt Ihcrefmm sad the basis for the alleged emmption.Arm violation
of Section 7031.5 by any applicant for a pered isublec,s the applicant to a civil penalty
of not mareman five hundred dollar.a500f A PN Number Occupancy Type
01,as owner of the pruperty,or my employees with wages its their axle compensation, 35708022. L710
,,If do the A I dhe am,,... tintended ft I l (Sec.7114.
Bn,i l f Code:tire< t t Lacruse t pplyati Required Inspections
r efprx
gty Whon 'Id , ,pnvesd a,maudwho hcs such work h resell 305 — FRAME
or through his train employees.provided that.aim improu'emaos are nal rumored or
oBcmJ air.ale.B:however, he Wilding or impmvemen,i,and within one year of 307 — I NSLIL AT T ORI
eminfr�l.,forrr>�«lsale.jrwaBhave meburden arpnwingmalheaienotbaimm _F01 — ROOF TEAR OFF
01.a,miNoes(tire prapeny.arewillmvelyconmerng with licensed e.ntraetar.to 602 — ROOF PLYWOOD I\IATI_
construct the proicei(Sec.7114,Bns s and Profession%C'nda)'the Contractor's
(ensc l.aw doe,nn apply mann `al prolerty who houldsa improve,thereon, 603 — ROOF BATTENS
aid whe contract,sir such proles atwith a antntetuBs) haa.ed pursuant m me 604' — ROOF II51—PROGRESS
Ctrntmeme,License law.
❑1 am enema audit,Sec. .B R P C far this mason
owner Date
WORKER'S COMPENSATION DF.CLAHAr1ON
I trashy mlln r under penalty nlperjury rare of 0e following Jcdarafon:
I have and will no/m min a Cenitieoc of Consent to self-insure for Worker's
umlenmtion, ns provided for by Section 3701 of ,he Labor Code, lir the
performance of the work for which this pemuit is isaaf.
01 have and will,aain,aio Worker's Compamsation Insurance,as require)by Section
3700 of the Labor Code fen the performance of me work for which this permit i,
cued My Work e Cr,11-nsry rt
uo Inver:uecarrieranJPulicymm�Mrnm�-
�71�—'jr-s� �a
en � �+ 1—Pricy No: ISY
QI!R'FIE PION(yrExEMPI'ION FROM WoRK17RS'
COMPENSATION INSURANCE
This sohio.urccd not ho anmfleed if the permit is far one hmrJmd dollars
($100)or less.) '
I amity that in the Ierfornancc of the work tie which this permit is i....rl,I
,hull net employ any parson in any ncmnea so as a,hcaotnc nurc,r u, he W..for, ,
Ci mperosal L:Iw,of CWuarnia.Dau
African,
NOTICE I U AIPPI.ICANT.If:atter making this Certificate of FAciaption.You should
bectrme subject or the Worker,Compensation previsions Orme Labor Code.you ma,.
O 0 forhx'ith comply with such provisions or this permit shall be deemed revoked. s .
Z
^F
CONSTRUCTION ac N,B ENDING AGENCY -
I hcnhy chino that,there its ,awd(Set.
097,lending agency li.,hc perfonnancu
W IZ
.11 the work ave which this permit is IxstmJ IScc.3119].Civ,CJ
7 A Lender',odea(Adder
7 Leader., .,
V O 1 moify that I have mad Ibis application and state that Ire above information is
Lr.r F' corer I agree m comply with all it,and auump ordinances and ,are lax,relating
O I, to Wilding enmuuction.and hereby authorim reprcumaives of this city to enter own
,he bu m mi J lueovey for impovii f pa
F. 0.
(We),Agme or sere,ardicirmodyandk p hanalesstheCty of Cupertino agansr
fn Iablt Jy reteoll, md ur,was,,Illicit all -1 to VoL,awlitot knnasort
U CITY , ... .. b y nhi t �\ ```a
SOURCE UNDERSTANDS
ANU WILL COMPLY WI fit ALL NON-POINT Issued by: Dale `
Signature of Apprcanvcommcmr Dom Re-roofs
HAZARDOUS MAI EIRIA S DISCLOSURE
Will the applicant or future Wilding occnrant,lom or handle haaamlou,material Type of Roof
uv dclined by the Cupertino Municlp:d Coale,Chapter 9.12,:,tad the Health and Safety
Cade,Sellinn 255320pI
O Yes GNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rather ham;Jing occupant use eyuipmcm or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hazardous air contaminants as de tried by me Bay Arcs Air Quality Mmnt,
anagee
r lace all new materials for inspection. Applicant understands and will comply with
0 Yes 0N all non-point source regulations.
` I hum mad dm hmarfous materials reyaimnarms ander Chapter 6,95 of the .
Culifouru Ilcdlb:l'i Safny Cudc.Secmms 2551$.25533 and 25514.I understand tor-
if,It,
o ifine building does not eurmn,lyh:wcu ren:rel lam i,is my rcpon,viol By m nmlty the
occupant of the requirements which must be mer pdnr m Issuance of a Cenificme of
`)"rpme, � S ,nature of Applicant Date
ownwtrr authorized spam Dam All roof coverings to be Class "B"or better
OFFICE
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY 4 2
Sec: Twp: Rug: Sub: Blk: Lo[:35709022.00
DATE ISSUED..... . . : 11/13/2000
RECEIPT q.........: 13993
REFERENCE ID 4 ...: 00110058
SITE ADDRESS .....: 10270 SCENIC BLVD
SUBDIVISION .......
CITY . . . . .........: CUPERTINO
IMPACT AREA .......
OWNER . . . . . . . .....: CULVER STEPHEN T AND ELAINE L
ADDRESS . . . . ......:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2726
RECEIVED FROM ....: DAVE S
CONTRACTOR . . .....: SAGOR, JAMES LIC It 22042
COMPANY . .........: WESTERN REGION ROOFING
ADDRESS . . .... ....: 231 N 12TH ST
CITY/STATE/ZIP . ..: SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408)360-9111
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REG NEW BAD
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 19,000.00 247.00 0.00 247.00 0.00
BSEISMICRE VALUATION 19,000.00 1.90 0.00 1.90 0.00
---------- ---------- ---------- ----------
'• PERMIT : 248.90 0.00 248.90 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 248.90 17141•
TOTAL RECEIPT x248.90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ............................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS