03050082 (2) A CITY OF CUPERTINO
BUILDING DIVISION PERMIT
Bu.DING ADDRESS: - BUENTIEMPO ROOFING PERMIT NO.03050082
173S REGNART RD
OWNEWSNAME: 412 HERSANER WAY PERMTf EBU 97 9/2003
?1NZ DIANE P V / l
NE' (408) 371-1879 SANITARY NO. CONTROL NO.
ARCH17ECTMN01NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
�00 LICENSED CONTRACCHI'S DECLARATION lb Description
I hereby afliml Thal 1 am Iwased under prrommw mo
of Chapter 9(com
cncin{ p
wish Sccfon7=)of DIWaior3of theeusinw PromsslnntCade.andm licensure
infull forte antl yn.G 3
Ll len Class. Lk.M v REROOF
Dem Contra'""
ARCHITECTS DEC rl y�r�w^
1 understand my plow shall he wed u public records r V i •'
5 G
SEP 1 9 2003
Licensed Professi...
I
OWNER-BUILDER DECLARATION
f i berthy.Bron this I I.S.exempt from tiro Gamuts Co License law for Ibe
p o fallowing tenon.(Section 703 coteBualnal,and impacts.
de oli h,at Any city or county BUILDING
which its Isms permit re rnnswct,slur,imptnsu demolish,nr a pair any msuclustatement Fly
prior its lssuanee.also requires the applicant for permit t9 ale ulgnaJ.mmmcnl
s0 thatheislicensed pursuant tothe Provisions nrtheComewor'slJcevelaw(Chapter 9 Sq.F[. Floor Area $ ty ion
$ (commencing with Sacdan7000)nf Division 3 of the Business and Professions Code)or
that hels exempt therefrom and the basis for the alleged exemption.Any violaden of
Section 7031.5 by arty applicant for a permit subjects the applicsnl M•civil penalty of 3 9&444-D4i4er 0 0 Occupancy Type
not mon than five hundred dolman(SSW).
❑1,As owner of the prapeny.wmy employees with wages asdeirwle compensation,
.tilde the woh,.nd Ne.budure is net mounded"offered fortam(Sec.70,44,Business — Regg�ired Inspections
And professions Code:The Cord w as's Licenc Law does not apply to an mor"of 3 0 7 - I NSULAT 1of p
property who builds of Narrows thereon,and whodoessuchworkhlmselfor through his
own employees.provided that such improvements Art not battered mortared forsal.It. 601 — ROOF TEAR OFF
how wr,the building or Improvement is sold within one year of completion,the owam,
huilder wfl[have the burden of proving that he did am Wild or Improve for purpose of 602 - ROOF PLYWOOD NAIL
sale')' 603 - ROOF BATTENS
❑1.Aa owner of the property,am exclusively contracting wide licensed contracm.to
construct the project(Sec.?W,Business and Professions Code:)The Contractor'.Lb 604 — ROOF IN—PROGRESS
cense law docs not apply to an owner of property who Wild.or improves thereon,and
who Contracts rot such projects with a controctor(s)licensed pursuant to the Contnetofs
Liccnm Lcw,
❑I sett exempt under See .B&P C fns this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby&Man under penury of perjury one of the following deductions:
I have and will mainuin a CeNRwte orconsem to asW naure for Woher's Compen.
Alton,As provided f"by Section 3700 of the LAWCode,for the performance of IN
work for which this permit is instead.
❑I have and will maintain Worker's Compensstion Insurance,As required by Section
3700 of the labor code,for the perimarance of the work for which this permit Is isw 1.
My ark raCjm eTs n Ins�Cye�aP(+and Policy nu
Cans — Policy W
CER7IFlCATE OF EKEMPI70N FR ORKERS'
COMPENSATION INSU ANCfi
obmsecdon wed not becomplched if the rcmtil is intone hundred dollau(SI010
w Ira)
1 certify that in the pufarmance of the work for which this permit Is issuer,l Nall not
employ any person in any manner an As to become subject to the Workera Compensm on
Laws of California.Dem
Applicant
NOTICE TO APPLICANT.If,after making this CenlOesm of Exemption,you should
become suhjm to dee Workers Compensation provisions of the labor Code.you mum
0 o forthwith comply with such provisions or this permit hall be dammed mauled.
z rrNnCONSTRUCTION LENDING AGENCY
[—, I hemhyafntm dust Nen Is a consorted..lending agency for the la:rfonnance of
6i the work for which this purred Is Issued(Sec.3097,Civ.C.)
W Q Ler,mes Name
G 4ndef.Address
U 0 1 ecrtify that 1 have read thla application and sum Nm the above Information Is
W cone"I agree to comply with all city and county ordinances and sum laws relming to
0 Wilding cowuution,and hereby Authoda repre.enugms of this city to carer upon Ne
W shove-mentioned property for inspection purprICL
gy (We)agree to ave,Indemnify and keep haindeu the City of Cupertino against
to Imbilides,judgmenu.casu.ndea hi In any wyac"uc egWtstssm Chy
V 7 In cansegwnee of N n ting of Ni c It
F7 APPLIC UN RS ANDS W L OMP4Y WITH A L NON-POINT Issued by: Date
CE
SOURGUL C `O�
` Re-roofs
SWUvre of ApplicanVConlranmr Dam
HAZARDOUS MATERIALS DISCWSUR Type of Roof
Will the applicant or futem building occupant more or handle huardow material
sa infinod by the Cupmrtloo Municipal Code.Cbapmr 9.12,and the Health and Safety
I.q.1m.
de.Section 25632(.)7 All roofs shall be inspected prior to an roofing material being 6jae� p p � y g g installed.
Will Nc applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havrdnw Air cormad. u d by the Bay Art.Air Qoaiity Management all new materials for inspectip.
mrict7
❑Yes u
Iban&SArread 1 the huatdnutmueil requ eau underCMpmrd93 of We Califog ^ / gd
HcmlhGSmetyC tiaw23 S. S J235J4.Iundcmm�tlNAtlfdmWilJin \/) Cesnoten rely h a mnanm It' y penaNllllybnotify de ace I of the it.nm p beme ' OSignature of ApplicantDate
c raaNariss steel .m All roof coverings to be Class"B"or better
CITY OF CUPERTINO S� 8
REROOF ° 3 t�
CUPEkTINO PERMIT APPLICATION FORM
APN # �� / � Date:
Building Address: /O6
117 /7E n fior IZfJ ..
Owner's Name: ry ^ Z— Phone#: i17-I
Contractor: tJ/I�I Phone#: License#: 6
C-vfT1Gp{ 1 � 1` ' lt� � 6 z1 2
Contact: l2� Phone#: N N Cupertino Business License#:
�1L Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 1`�Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) Fo Alw 5�7 In Y ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
6'�To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
T6-19-Ar d FFFGR4/^ r� �, n
sh 1 ���'�� � � nuc
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Det. if
there are any restrictions: LJ
Cost P4,ect: Type of Con*WaVftnp Occupancy group:
Qty. if
A p p Yc'4—b)e Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
TL BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING