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05090046 (2) CITY OF CUPERTINO r M1a :� >" "" a " ' BUILDING DIVISION PER � ONR�,CTQR"I} ORMATIO BUILDINGADDRESS: CASTO ROOFING PERMIT NO-05090046 OWNER'S NAME: PERMIT 05U9 DATE AK M NE: SANITARY NO. CONTROL NO. (650) 961-8922 ARCHITELT/ENGINEER: BUILDING PERMIT INFO BO ELECT PLO o LICENSED CONTRACTOR'S DECLARATION gem"I 1 hereby film that 1 am licensed under provtaions of Chapter 9(commencing Job Descriptibri {� wiN"to..IX Off Division Jof tie Butlness redP egstuny��And my license is e w mfullformanl cffae �-77 //L 3 REPIPE 14a7/E� iJR It/LfjL➢+ j�Z Liceiuc Clam J Lk. L Data Co.,. ea ARCHITECTS DECLARATION sEPaa Too y 1 undcrNnd my piste shall ha used a public mcnrds Licensed Pmfcaion 3 al 5 4�[ OWNER-BUILDER DECLARATION i a I 1 hereby affirm that 1am 1. .Bumps from He Cssions ora Licence Law for the D� foll.wwhich [cress. erte(Section co 1.3,Business and Professions Cade:My city or county which its iasopermit acconstruct,alar,improve,deermitt ore a sig any structure f` h,Zy Prior mitsissuam0.aru requite pmvisio of for Cor Permute Russe signedsta tement that he islicensedwait pursuant to the of Division ivision 3 He Co tenant,Uccnmlaw(C Code)or Sq. F[. Floor Area Va unction (car3g that he s axem WtheNromon and of basis n3 of theBusinessexe Anton.My Profession, )of .$10500 Net Section r u1,5 b therefrom and Ila bur for tie alleged exemption.to Any violation of not than by hurt red dont fora permit subjects Ne applicant m a civil penalty of APN Number Occupancy e mol mom than five hundred dollars(5500). P y ZYP [ Lasawmrofthe property,ormyemploymwith wagesu thalrsdecompensation, will do Newark,old the saucture r not Handed eaaffercG for We(See.TON,BUNes, 00 and Professions Code:The Conlncme,License Law does not apply in an owner of Required Inspections property who Animism improves Hereon,and who des such work MnsmU ar ds wulh his man employes,provided tat uch Improvements an not Hunded aoaertd formic.If. however,the building w Improvement is mid within one you of completion,me owner builder will have me burden of proving that he did not build or Improve for purpose of umJ. ❑1,a owner of the property.Area exclusively connecting with licensed commusm in concoct the project ism.7044,Business and Professions Cade:)M Contributes Lt. cense Law dam no,Apply in an owner of property who builds or impmm mertm,and who contracts for such projects with a conlranor(s)limmand pursuant in the Contractors License Law. ❑I am mempl under Sec ,B k P C far this came. _ Owns Dale WORKER'S COMPENSATION DECLARATION I hereby million under Penally of perjury one of Ne fallowing declandons: . 1 ham and will mounds aCenificem of Comnt in sel6lnsun for WarkersCompen- 137'10 on,u provided for by Section 3770 of Ne labor Cade.fee the performance of the rk for which this permit is issued. 1 have arm will maintain Workers Compensation Iwnnce,u required by Section of the labor Cade,fes Ne performance of tim wart for which this peropi r issued. Work ComPeuLadonWunna artier end Poliry numrare:rrier. vv"`"'1- PoIIry No:2- �ZU OS CERTIFICATE OF EXEMPOON FROM WORKERS' COMPENSATION INSURANCE . (Thr sermon need notbccompkud lithe parrot,rfor.headed!dollars(SIa(r) or leu.) I unify that in the Performance of the work for which data Permit is Issued,l shall not employ any person in any manneran AS u become mbJcot to the WMIXTS''Compensa0on Laws of Cmifomta.Data Applium NOTICE TO APPUCANr:If,aper making this Ccnificee of Exemption,you should become subject in the Worker's Compenaadon Provisions of the labra Coda,you muss .J O raMwith comply with tach pmvriou or Nis permit Nell be deemed mated. 'Z CONSTRUCTION LENDING AGENCY 1Amehy.M.that Nero is a coearctwe lending agency for the perfurmenmaf IY> the wart for whim this permit Is issued(Sec.3097.Civ.C.) W�Q Lenders Name . Q z Lemler.Address V Q 1 certify that I haw raid Nis Application and mm that the above Information is L4 comcct I at=to comply with all city and county ordinances and state laws relating to Q building construction.and hereby authorize mpresemutim of this city in enter upon me W above-mondoned property for inspection PUPuet LL (we)agree m save,indemnify And kap harmless the City of Cupcnino against liabilities,judgmeme,casts and esteems which may In any way acme against said City U in consequence of the granting ofi" permit r r APPLICANT UNDER TAN A WILL COMPLY WITH LL NON-POINT Issued by: Date SOURCE RE A "ez / Re-roofs S .� isms pit ter Dam AZARDOUS MATERIALS DISCLOSURE Type of Roof ' Will the applicant or future building occupam mom arhandle huardous material u dented by the Cupertino Municipal Code.Chapter 9,12,and the Heald and Safety C ode,Semen zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yee ' Will Ne applicant a future building amupmt um equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove W havardous air comaminan"u dented by Na Bay Area Air Quality Management all new materials for inspection.WietP I have mad the hoard uuR a tials requircmcnu under Chapter6.95ofthe Califor. HcallhA SmmyCom,Scttiau 25505,25533 uu125534,1 undessund Nat IINe Molding ra not cuncn0y haw Len alitr my respouibllhymnWly Ne oceupanl nflMmntuu inch anmonclityMm % ignatureofApplicant Date All roof coverin s to be Class"B"or better It, LO Col Dam g } r Community Development 10300 Torre Avenue ( ! ; Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 $UPEkTIN.0 Building De artment JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # S0 F2- GENERAL CONTRACTOR:- CV hga''�oa/N y—vieFAX # 'r I am not using any subcontractors: ` t,J1 Signature ;. h , Date Please check a licabl subcontractors and complete the followinginfbrmation: 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 /J�© �— i er/Contractor Signature Date I •I CITY OF CUPERTINOS^U o L3 (� RF,ROOF CUPERITINO PERMIT APPLICATION FORM API # ©O S Date: 1� Building Address: S '758, afe( ' )ford �C Owners Name: Phone#: U(-0. f5v Contractor License#: Contact: Cupertino Business License #: Toni Souza Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles ❑ Asphalt Shingles Wood Shakes IB Wood Shakes Wood Shingles O Wood Shingles ❑ Other(Specify) ❑ Other(Specify) 7N her of existing coverings 7 ❑ Provide I.C.B.O. Report# Cd" To be Removed ❑ Provide Mfgn Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: Job Description: ea,- off-C arx6 L%Vpt.j IIecw �tre.+rec kee( _gAcL=eS Residential M Commerciar❑ Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if there are any restrictions: LJ Cost of Projecfp7Br 5-00 Type of Construction: Occupancy group: 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