07110012 CITY OF �UPERTINO r �� , � T ��������,��`�}������*
BUILDING DIVISION PEl�1vuT ; <:; .- - "`" PERMITNO.
BUILDINGADDRESS: WESTSHOR� ROOFING INC 07110012 •
10170 N BLANEY AVE _ ��.�DA
vsR 'SNAME: 281L� AIEl�LO DR C � 11/02/2007
PRAVIN SINGHAL SANI'fARYNO. CONTROLNO.
PHONE: (408) 694 -0060
BUiCAING PERMITINFO
ARCHI'i'EC'1'/ENGINEER: B C] E [� pL O M �
u O z LICENSED CON7'RACf�R'S DECLARA'I70N IOU DeSCi1pt10I1
� z� wi�h Scc o 7U00) o Division 3 of Ihc Busi�cs�r�d �ofcssions Codc, and my 1 cense is RE — R00 F � l�N� 1 LYR WD S HNG L S, I N S T L � S B , I N S T L
�<a infullfomean �� f'Z.�Z/� PRESIDENI'IAL TL� 15SQ � CLASS A
� � Licensc Clus � L � . � -'� :� � � lw. -S,/y�
' `�^ Dam Contracwr
� � u��, ARCHITECI'S DECLARA7
� a< 1 undcrstand my plans shsll be wcd as public rccords
�yU
y W� y Liccnscd Prufcssional
� OW NER-BUILDER DECLARATION
�<� hercby alTirm ihat 1 am cxcmpt Crom �hc Contractor's Licensc law for thc
p O following rcason. (Sc.ction 7031.5, Busincss and Profcssions Calc: Any cily or county
� m Pi which requiccs a prm�it to construct, aiter. improve. domolixh. or �epair any swcwrc Valuation
+�'" y priar w i�s issuanc c, a l w r c q � � t c s U� a p plicml for such permit to filc a signcd sla�mcnt c Ft. Floor Area � 1 O O O O
—?< ihat t�c is licensed pursusnt to the provisiona o[ ihe ConUacac's Liccnsc Law ( C haptcr 9 � q'
Y� � (commencing wi�h Secdon 7000) pf Division 3 of It�c Busincss nnd Profcssions Code) or Oecupancy Type
i�� a � � is exem pt thaetrom md the basis for the ailegcd eumpdon. Any violauon oC Number
Secdon 7031.5 by airy applicant for a p�c��� � b j e c u i h e a p p i i c a n t w s � i v i l p enalty of 3 1 6 3 1 0 2_� ��
na more �an fiw hundred dollars (SS00)•
� I. u owner o[ ttie proPettY• or my emptoyces with wages u their solc compensadon.
will do ihe work. and the stcuctwe is not intended or offeced for sa� (Sa. 7044. Business
Required Inspections
and Profasions Cade:'ihe Conuactor's License Law docs not apply w aa ow'ner of
Pro N ,h o y�i�� a�mprov�s �hercan, and who das such work himse�[ or Ihmugh his
own employces. Provid�d that such improvemen�s arc not in�ended ar oRered Cor sale. I[,
however. the building or impmveme�t ia sold within one yeu o[ comP�� [or purpose o�
builder will have the burde� o[ proving U�at he did not build ar impro
sak.).
0 I � �,� o [ � propeny. am exelusiveiy cont+acting wiUi licenxd convacmrs w
conswct Urc p�ject (Sec. 7044. Businas and Pro�essi �ild ��mproves �heceons� .
ccnse Law does not apply w an ownu of property �nt ���n�or's
who contracts Cor such projecu wiih a convactor(s) fice"xd F"
License Law• , g� p C for this reatoo
' 1 am exempt undu Sec.
Date ��
,nor
WORKER'S COMPENSA'ITON DECLARA'11�
1 hereby alTirm unde� panalty of P�rjury one o( �he tollawing declarations:
� 1 hs+e andv dcd for b��Section 3700 of �he Labor C l odC for the peifarmancc of Ihc
satian. as pro � Y
work for which �his pertnit �s issued
� I havc and will maintain Worker's Comp�nsation lnsurance. as �c9uired by Section .
3700 of the Labor Codc. Cor ihc Pedormantt of the Wrort for w6ich �his perm�� is �ss��d
My Worke�s Compenution Insunnce cartier and Policy numbcr aze: ^ 2 �
Cartiu: _��.F�il��f Policy No.: CO A� '
C �� COMPENS�ON NS RANCE �
('mis ycction need not be complctcd if tde pertnit is for onc hundrcA duttacs (S l00) '
or Icss.)
I cenify thnt in thc perfortnancc af thc work for which this permit is issued. I sha0 not
e:nploy any pecson in any manner so az w become subject w U�e �Yorkers� Compensatlon
Laws of Califomia. Da1c
Applicani
NOTICE TO APPLiCAM: If, aftcr making �his CcriiGcate of ExempGon, you shoul
become subjxt w �Ac Workcr's CompcnsaGon provisions of thc Labor Codc• You must
�;� forthwith comply with such provisions or this pecmit shall hc dcc+ncd mo�d.
z � CONSiRUCT10N I.ENDING AGENCY
�� I��by affirtn ihat thcre is a consuuctian Icnding agcnry 1'or thc performance o[
p(, ,7 tho work fur whic6 this parmit is issued (Sec. 3097, Civ. CJ
(da Q Lendc�s Namc
p+ Lcnder's Add�ess
I cenity U�at I haw resd ihis apPlieauon and su�e �hst �hc aboK informaliun is
w� corten. l agrce to comply with all riry and counry onfinences and sta�e laws relaung w
U building consuucaon, and hereby autAoriae representativcs of �his ciry w cn�cr upon thc
� above-mcnuoned property (oc �nsP�ction purposes.
�"' W (Wc) agree to save. indcmnify and keep harmless the Cily a[ Cupertino against
„H� � liabiliucs, judgmcnu, cosu and expenses which may in any waY acccuc agamsl saiG C��Y D ate �f��
V z in consequence of the granting of �his permi� �
►+ APPLICAN'f UNDERSTANDS AND WI COMPL WITH ALL NON-PO1NT Issued by:
SOUR A170NS. .�
vt Re-roof:, �'�
��u�� ar �u dc
a� ° a Type of Roof
({pZpRDOUS MATF.RIALS DISCLOSURE
Will lhc applicant or futwe Iwilding accupant uorc a handlc harardaus ms�rial
;ftncd by the Cupenino Municipal Code. CtisP�c� 9•�Z• �nd [he Healih and Safcry
.�. Scction 25532(a)? All roof s shall be inspected prior to any roofing material being installe .
❑Y� '° If a rooi' is installed without first obtaining an inspection, I agree to remove
Wql� tho applicant or futucc bui�ding accupant usc eyuipmcnt or devices which all new materials for inspeccion.
cmit ha•rardnus air conwninants as cicGncd by th� B�Y A�a' ����y Managcmcnt
Disvict?
� y u � '
1 havc rcad �he ha� �s �ria� �9�iremcn�s undcr Chaptcr 6.95 of �hc Cali(or- � � 2 � t'
nia Hcalth & SafetyCodc. Sections 25505.25533 anJ 25534. � undcrstand thaz if ihe 6uilding D
docs not currcntly havc a tcnan4 � it is my rcsponsibility w nudfy thc °aupuu M ihc
requircmcn � m �� P�Of
�a�� • ign ture of Applic
All roof coverings to be Class "B" or better
Da
ncr or aWhari a nt
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI7' RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN ......... 31E>31023.00
DATE ISSUED.......: 11,'02/2007
RECEIPT #.........: BS�)00003145
REFERENCE ID # ...: 07:_10012
SITE ADDRESS .....: 10L70 N BLANEY AVE
SUBDIVISION .......
CITY .............. CU?ERTINO
IMPACT AREA .......
OWNER ............: PR�VIN SINGHAL
ADDRESS . : 10170 N BLANEY AVE
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2330
RECEIVED FROM ....: BE[� FOWLER
CONTRACTOR .......: PAUL FOWLER LIC # 21417
COMPANY ..........: WESTSHORE ROOFING INC
ADDRESS . : 2814 AIELLO DR C
CITY/STATE/ZIP ...: SPN JOSE, CA 95111
TELEPHONE ........: (408)694
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----------
---------- -
--------- -----
BPERMFEE VALUATION 10,000.00 169.56 0.00 169.56 0.00
BSEISMICRE VALUATION 10,000.00 1.00 0.00 _____1_00 ______0_00
---------- ---------- -
TOTAL PERMIT : 170.56 0.00 170.56 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ---------------
CREDIT CARD 170.56 MC
---------------
TOTAL RECEIPT : 170.56
0"1 I I c� � I 2.,
CITY OF (:UPERTINO
���- RE�ZOO�
CUPER�TIi�lO PERMIT APPL ICATION FORM
APN # r �� Z � . /� O Date: 11 I Z 6�`
3��3 � �
Building Address:
lv o N• �n� A��
O«ner's Name: , �� I Phone #: 2 S,� �/ 2 6
I'Y1 t• P� a �� v� s i n ~
Contractor: License #: � $ � � .� (
WeS�3�oY (�oa i ilnc .
Cupertino Bu� � s�L � �se #:
Contact: , f� �� � � �L(Jg� � �l y ' O�bV
C��. b r► �e 1 ��
Type of F:oof 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 �
0 Provide I.C.B.O. Report #
� To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With Cupertino's Tear Off Policy:
7ob Description: Q, c v+� uv`�C 1 l K y t� wo � Sh �✓�� k 5� 11�. S f��� V 5 Q� j✓� 5�'a �
�'�s; d �c v� � � �. T L ► �
Residential �' Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning De_pt. if
there are any restrictions: U
T e of Consfiiction: Occupancy group:
Cost of Project: � UI v �� Yl� 5�(�
C ' 20a�
Qty. if Fee Description Fee Group
Applicable Fee ID
BPERNIFEE Bldg Permit Fees BLTILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING