08120016 CITY OF CUPERTINO
B_4(LDING7)IVISION PERMIT
BUILDING ADDRESS: PERMIT NO,
21979 SAN FERNANDO AVE TB OWNER'S NAME: - PERMIT ISSUE DATE
A CONTROL NO.
pAt�LmA DTa
ARCHT7ER/ENGINEER:
BUILDING PERMIT INFO
' BLDG ELECT PLUMMECH
0 0 0 0
a 0 o LICENSED CONTRACTOR'S DECLARATION Job Description
�r 1 hereby affirm that l am licensed under Provisions of Chapter 9(commencing
wash Section 7")of Division 3 ofthe Bass.am Professions Code.am my license is
;H lomnroemdeffect RE—RF RMV OLDRF & RPLC. W/STNDING SEAM METL RF SYS
7coreZ License Class Lk.0
oak Gumnar ON EXSTNG PUBLC RESTRM BLDG
aa ARCHITECTS DECLARATION
Wu 1 mdervsnd plans my pu shall used a pulite rrswds
Pn
l G� Licensed professional
5 OWNER-BUILDER DECLARATION
i F I hereby aRre,that I am caempt from Ne Convenors License Law for Ne
no following reason.(Section 70313,Businns am Prefosslav Cork:Any city or County
u$ff which sequins a permit to Corswet,alkg hnprave.dcmNuh,Or repair my s rectum
zr prior to is issuance.shm requires is applicant for.ach permit an file a signed. COMMI
SSC thatheislicensedpursuantktheProvisionsoftanCommeamfLicenseLaw(Chapter9 Sq.Ft.Floor Area Valuation
rths (eonmemsing with Scodon 700))of Division 3 of is Business and Pmfrsions Code)or
Q that he is eumpt therefrom and to laid for the alleged exemption.Any violation of
section 7@1.5 by an,applicant fm a permit subjects the applicant m a Civil Penalty of APN Number Occupancy Type
not mom than five humid dullard($50E).
❑1,ssownnoftheproperty,umyamployceswithwagesastheirmleeonpemadon, 35710005 . 00
will do the work.and the structure is not inkmcd uoffecd for rade(Sec.70x4.Burow
am Priam m
fevCada:The camrlarr Llan¢law deed sat apply to an Comes err Required Inspections
ptepeny won Wilds orimpmves theto m,and who does such work hirxelfor 0hough his
own amploym,provided that sash improvements art an,intended oroRenm fusyn If.
however,the Wilding or imprwmmt is sold within au your of completion.the owns-
Wilder will haw the WNeo of proving that he did not Wild or improve for purpose of
sale).
Ud'1./a owner of the property,am exclusively consumers with licensed Cm mer In
crosuun Ne pmjen(Sec.7066,Bmimuv am Prafesdav Cmc:)The Contrmlers Li.
cove law dean not apply to m Cann of property who Wilds or improves thereon.and,
who comms far inch prjeeu with a Conuator(t)licenced pursuant m the Contactors
Liccnm Law.
❑lam pt under Sec. ,B&P C far this raven
ownu�Gl✓(= Data !22 0
WORKER'S COMPIENSATIU4 DECLAR&MON -
I hereby anim under penalty of perjury on of is fallowing deelamias:
i Mw and will mom o.Cerificeuof Comet m elf-insue for Workers camper
don,as provided fu by Section 3700 of the labor Code,for the Performance of the
were fu which this permit is issued
❑1 have and will mainuin Workers Compensation Insursn¢,u rtqubed by Satan
3700 M the Labe Cade,for Ne Performance of the wank for which thu Permit s issued.
My Warkcrs Campewton Insvnnae carrier W Policy number err:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
rn iarMlon ism nctheeonPkkd if the permits forum hundred dollar($100)
or Coal
1 ratify than in the performance of the wort fu which this premia u Wood.I shall not '
employ my pcnan in my man m beco ac mbj outhe Workers'Comprnaton
Laws of califs a Daa—1 31
Appliom P
NOTICE TO A PLICAN.If,sMr ting this CC 'fins of Esemption,you should
became subject u the Wades'.Com mumdon psnn iev of Ne LaWr Cade,you mus
.J O forthwith comply with such pravktiom o Nutmatd
petit Nall W assumed e
y .yN.. cONSrRucnON LENDING AGENCY
I hereby affirm thaa which Nu PerVert sea conswction lending agncy for the perfournmen of
Ne conk fuw
6. mit u issued(Sex.3 ,Civ.Q
Lenders(as
a Z Lambert Aaareas
U Q I coolly and I have read this application and sera and is add.information is
Ix.^ carat 1 agree to comply with all city and county ordinances and sea laws relating m
-C)rV' Wilding Construction,am hereby m0raim repracnutided of this city to enol upon the
r 4 a Ww-metiooed property for impenion purposes.
(We)agree to ave,indemnify and kap hamlw INC City of Cupertino.gaunt
nHi y liability judgments.casts ad eapensu which may in my way assets,Mariml road City
V Z in conu,mrsec of the granting of this permit.•
.a APPLICANT UNDERSTANDS AND WILL COMPLY WrIH ALL NON-POINT Issued by: Date
SOU?!REGULATIONS.
'r^r Ana_a [w l� I 0� Re-roofs j
Signature of AppliunVConuacmuDak
HAZARDOUS h ATFRIA[S 0$CLOSURE Type of Roof
Will use apPliant a future Wilding attupantnom orhamk ha of ou makrial
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Haa1N and Safety
Code,Semon 2.5532(a)7 �7ro/ All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will the applicant or(stun Wilding occupant use equipment or dcdices whet<M1 If a roof is installed without first obtaining an inspection,I agree to remove
it headers air cmourrim us as defined by to Bay Area Air Qmallly Maugcmcnt all new materials for inspection.
'suint �d�//
❑Yos rQN.
I Mw rad to hos daus;rtukriaHrequhcmcw udcrCMpurd95 of t eCalifor.
nia Hahh&SafctyCode,SaUam25505.25533 md25534.1 undcumnd NatifNc building
does ret arrendy Mve a Curl and it I.my mapemiNliry m etify is occupant of Ne
mcgmrt watch ambemCt arthissuance nra mrCakara piney. Signature of Applicant Date
n
OwnerwNarizedasd A .aggenort t I U
1 2/unarc4� All roof coverings to be Class'W'or better
'
CITY OF CUPERTINO �' �) a p0
S,
REROOF
CITY•CUPEI�TINO PERMIT APPLICATION
APN # Date:
'15r71 Obr_>15 ; 0o
Building Address-
2-
ddress: n
J rviv
O(w'ner's Name: Phone #: q0-6 -7-7-7-3'Z I'S
Contractor: Tes Phone #:
Fax #:
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof u Built-Up roof
V- Asphalt Shingles ❑ Asphalt Shingles
oWood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) V- Other (Specify) Nndiol gea.r Melo
Number of existing coverings ❑ Provide I.C.B.O. Report` yt
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: Rt v-vtd V e, o 1 cl Yoo q r xa r-e.p I ctce vJ •4'L,
02jtavv\� t200-' SjS+ew• o 'n
�-R. f-rooVVN {3L&*, I CL /I
Residential El Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
s C", g,,�
Signature
Revised 6/16/08
CITY OF CUPERTINO
REROOF
CUPEI,TINO FEE SCHEDULE •
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1RER00FRES ' Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
IREROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08