07050162 CITY OF CUPERTINO '
BUILDING DIVISION' PERMIT �CTOR INEORMTIUN'
PERMIT NO.
BUILDING ADDRESS:
10713 RANDY LA CUPERTINO ROOF, INC 07050162
PERMIT ISSUE DATE
OWNER'S NAME:
AUCH EDWARD S AND LAURA 1052 KELLY DR 05/17/2007
SANITARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
TEAR OFF EXISTING SHAKE AND BLDG ELECT PLUMB MECH
CZ
ZLICENSED CONTRACTOR'S DECLARATIONIMSTAMJob Description
m p 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division of the Business and Professions gode,and my license is
a in full force and effe
License Cl s Lic.N
t Dam Contractor
AR ITECTS DECLARATIOINP 4&4
a< l understand my plans shall be used as public records
aV
U.y Licensed Professional
OWNER-BUILDER DECLARATION
7 I hereby affirm that 1 am exempt from the Contractor's License Law for the
in o following mason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior m its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 3q.Ft.Floor Area
Fz (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1.as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
�]I have and will maintain a Certificate of Consent to self-insure far Worker's Compen.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Wgrl aid o en ation lgwpnce carrier and Policy nu�b�r afire: �p {
Carriers'-1�i Policy No.:
CERTIFICATE OFJDCEMFn0N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
N
O CONSTRUCTION LENDING AGENCY
r►�-. I hereby affirm that there is a construction lending agency for the performance of
Y,.> the work for which this permit is issued(Sec.3097,Civ.C.)
t�Q Lender's Name
jz Lender's Address
C-) I certify that I have read this application and state that the above information is
L Hcorrect.l agree to comply with all city and county ordinances and state laws relating to
V building construction.and hereby authorim representatives of this city to enter upon the
w W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
y rA liabilities,judgments,costs and expenses which may in any way accrue against said City ` �1
z in consequence of the granting of this permit. Date J' _
�+ A CAM UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
UR E REGULA NS.
Re-roofs —a
of Appliant/Commmor Date
HAZARDOUS MATERIALS DISCLOSURE Type,of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes —'QN°
Will the applicant or future building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
-lhavc read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia h Code,Sections 25505.25533 and 25534.1 understand that if dsc building
cu ntly ave a tenant,that it is my responsibility to notify the occupant of the I
e s wh' st be met prior to i a Ccrtjfiea�ofocgrr Signaturc,of Applicant Date
DamAll roof coverings to be Class"B"or better
air d agent
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 31602042 . 00
DATE ISSUED. . . . . . . : 05/17/2007
RECEIPT #. . . . . . . . . BS000001361
REFERENCE ID # . . . : 07050162
SITE ADDRESS 10713 RANDY LA
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER AUCH EDWARD S AND LAURA
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2054
RECEIVED FROM . . . . : DAVE PRE
CONTRACTOR DACE SMITH LIC # 25701
COMPANY CUPERTINO ROOF, INC
ADDRESS 1052 KELLY DR.
CITY/STATE/ZIP . . . : SAN JOSE, CA 95129
TELEPHONE (4C8) 973-9427
FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 14, 000 .00 212 .76 0 .00 212 .76 0. 00
BSEISMICRE VALUATION 14, 000 . 00 1.40 0 .00 1 .40 0 .00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 214 .16 0 .00 214 .16 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -------.-------------
CREDIT CARD 214 .16 MASTERCARD
---------------
TOTAL RECEIPT 214 . 16
CITY OF CUPERTINO
RE20OF
ITY OF
CUPERTINO PERMIT APPLICATION FORM `7050/6
APN# 2/� Date: cl
Building Address:
Owner's Name:ff T) Y--) U C Phone#:
Contractor:. Lice se.#.
C u f)� fi� ��� 9 V�/ _)
Contact. Cupertino Business License #:
701
Type of Roof Covering:
Existing: Proposed:
❑ 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 Wilt Comply With Cu pertino's Tear Off Policy: ❑
7 �� tet - Sl�.e�� c I�,►S5� ��1 �c-c I �� RC1 r C i�
PA'S'
Resideulia—D Commercial ❑
Fire Zone: Yes ❑ --Nam] I Confirmed with Planning Dept. if
C l 5 there are any restrictions: U
Cosroject: Type of. is ction: Occupancy grou-
of
Uuo
Qty. if
Applicablq Fee ID Fee Description Fee Group
BPERMFEE F ldg Permit Fees BUILDING
BENERGY l3nergy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Sieismic Commercial BUILDING
BPLANCHK flan Check Fee BUILDING
BUSLIC 3usiness License BUILDING