03100110 CITY OF CUPERTINO
Buu.mnc DIVISION PERMIT CONTRACTOR INFORMATION '
1,. , I � a
BUILDING ADDRESS: PERMIT NO.03100110 3100110
OW NER'S NAME: PERMIT ISSUE DATE
NE: - SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MO
0, LICENSED CONTRACTOR'S DECLARATION
i u E I hath,arum but 1 am licensed ander prnvieians of chapter 9 rcommencing Job Description '
:zio with Scmi.A70(Bof Divisirn 3 of NC Businesxond Profession,Code,end my license is Q/
fmlmreeanaefr EROOF !�
f�2 cense Class Lica
;moo brim Cataracts CONTRACTOR: MDC ROOFING /1
E res ARCHITECTS DECLARATION
i C V I understand my plans shall be used a public mcnNa
°off Licensed Professional
OWNER-BUILDER DECLARATION
<S 1 hereby affirm that I am exempt from the Comracmr's License Law for the
:p o following reason,(Section 7031.5.Business and Prefenimts Cock:Any city or coumy
e m which requires a permit to construct,alter,improv,,demolish,or repair any structure
poor to its issuance.also requires the applicantfor such Permit to file a.signed statement
:s< that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuatispg500
2to (commencing with Section]fp0)of Division 3 or the B usiness and Proressions Cade)or
:3 Nat he is exempt th.mfrom and the haxis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to A civil penalty of
not more man five hundred dollars($500). 3 62Itl Mol4cr O O Occupancy Type
0 T.As owner or the property,or my employees with wages as their sole compensation,
will do the work,and the swctuor is not intended Or offered for sale(Sec.7044,Business
and Professions Code:The Contrumr's Lime Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does suchwork himself orthrough his NO ASSIGNED INSPECTIONS
own employes,provided that such improvements arc not intended oroRered torsion.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will haus the burden of proving that he did not Wild or improve fur purpose of
sale.).
0 I.as Owner of the property,am exclusively contracting with licensed comouctom to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense law docs not apply to an owner of property who Wilds or improves themon,and
who contracts for such projects wit a contractors)licensed pursuant to d¢Contractor's
License taw.
0 1 em exempt under Sec. ,B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under Penalty of perjury ane of the following declarations:
1 have and will maintain A Cenificam of Consent to self-insure for Workeri Compen-
sation,ss provided for by Section 37M of the La Wr Code,for doe performance of Inc
work for which this permit is issued.
0 I have and will maintain Worker's Comp.nsatinn Insurance.As required by Section
3?00 of the labor Code,ror dor performance of the work for which this permit is issued.
y Worker's compensadan Ins n ea .r and Policy number am:
Car Policy NO.: _
CTIFICAT OFEX PI'IONFROMWORKERS'
COMPENSATION INSURANCE
Obissecrirm need not becompleord Ktbe Permit is fair one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this Permit is issued.I shall not
employ any Person in any manner so u m beermt Subject o the Workeri COMNAmdon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cc"ificaor of Exemption,you should
become suhject to the Worker's Compensation provisions of the Labor Code.you must
�z forthwith comply with such provisions or this Fermi Ishall Ix,deemed muted.
Z 0
CONSTRUCTION LENDING AGENCY
1 hereby affirm mat mere is A construction lending agency for tbe performance of
Z Ne work fur which this permit is issued(Sec.Alit,Civ,C.)
4 Lender's Nam.
z Lender's Address
;J 0 1 ceniry that 1 hast read this application and all Thar the Above information is
S. (" cancer.I agree 10 comply with 411 city and county ordinances and$rate laws relating to
Z) building construction.and hereby authmim representatives or this city to crier upon the
C)
'hove judgments.
mentioned ProPc costs
land ca inspection purposes
y (We)agora to save,indemnify and keep harm leu On City of Cup.nino against
lnconsequudgmcnN,cramandofthis $which may in any way secret against mid City
..7 z in conmyucncco cBrantin of this '
^ APPLICANT ERST D D W L COMPLY WITH ALL NON-POINT Issued by: Date
#e0fApp1P:pDnoC0nLoaCtm
R CTION /
ScDare Re-roofsHZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the acnt or future building Occupant store or handle haiarduus material
As dcrined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Chun,section 25532(a)?
❑Yes ONO All roofs shall be inspected prior to any roofing material being installed.
Will mea applicant of future building Occupant use a If a roof is installed without first obtainingan inspection,I agree to remove
pp g p Area
of Mara mens P
it hvardnus air conmminanm u Jcfincd by the Bay Arca Air Quality Management all new materia for inspection.
istrin?
O Yes ON.
havcreadmcharardi smamrialsmquimwnuundcr ,Chaplcr6.95ofineCalifor-
nia)iwlth&Safety od.,S.c A255( ! S�3 and 25534.1urdcmard dot if be Wilding /O
does not current) won, Nott y/msponsibiliry I.roul'y the accuprou of thu
myui m y �inustE cli ho wissuan cola Ccrhfca¢of Occupancy.
*rofican Date
0 uthmixed ag.at f i I I Dare All roof coverings to be Class "B"or better
CITY OF CUPERTINO > 31
REROOF
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # 34, Z 3 O Date: O `
Building Address:
Owner's Name: Phone#:
0
Contractor: Phone#: License#:
Ko
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
}q 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 Will Com I With Cu ertino's Tear Off Policy: ❑
Job Description: ({�ry�✓/ W¢ 50Cf 5lt9f—e_5 0-7 ��rs�a7� P ealo� cD
O U
Residential [ Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are anrestrictions: i5
Cost of Project: p�Type of Construction: Occupancy group:
Qty. if
A licable Fee ID Fee Description Fee Group
Bldg Permit Fees BUILDING
ner BUILDING
eismic Fee Res BUILDING
eismic Commercial BUILDING
MPMR
lan Check Fee BUILDING
usiness License BUILDING
1 � 7 � o