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07050077 CITY OF CUPERTINO BUILDING DIVISION PERMIT � TkL� BUILDMMESNORWICH AVE T D ROCFING PERMIT07050077 OWNER'S NAME: PERMIT ISSUE DATE DAN & KAREN RUSSELL 675 TULLY RD 05/09/2007 NE: SANITARY NO. CONTROL NO. (408) 892-8872 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 30p LICENSED CONTRACTOR'S DECLARATION Job Description U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing ?z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is REROOF-REMOVE WOOD SHAKE, INSTALL 50 YR ;may L eneClasiull force de ��C{ � # RESIDENTIAL 30LB FELT-26 SQ,CLASS A ? License Clas t— pate Contractor CHITEC`rS DECL.ARATI 7 X< 1 understandmy plans shat)be used as public recur )yrJ win Licensed Professional y, OWNER-BUILDER DECLARATION 11 I hereby affirm that 1 am exempt from the Contractor's License Law for the Cp C following reason.(Section 7031.5,Business and Professions Code:Any city or county `<$ which requires a permit to construct,alter,improve,demolish,or repair any structure Zprior In its issuance,also requires the applicant for such permit to file a signed statement =a that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation uF $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $9450 u�§ 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 ' c Number Occupancy Type not more than five hundred dollars(5500). 3 1 6 2 9 O.9 ❑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 q P 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.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Conlractor's U. 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 Ute Contractor's License Law. ❑1 am exempt under Sec B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: L]1 hsve and will maintain a Certificate of Consent to self-insure for 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. have and will maintain Worker's Compensation Insurance,as required by Section 700 of the Labor Code,for the performance of the work for which this permit is issued. My Workers ompe satian ln3ursfi'e cam and Polity number`:/ �} Cartier lily No.: CERTIFICATE 'EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 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 0 forthwith comply with such provisions or this permit shall be deemed revoked. Z . CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performamm of Ri> the work for which this permit is issued(See.3097,Civ.C.) W�.A Lender's Name r7 z Lender's Address V 0 1 certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to 0 Vbuilding construction,and hereby authorize representatives of this city to enter upon the >4U above-mentioned properly for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against ,may t� liabilities,judg cotsLNS 'is xpenses which may in any way accrue against said City V z in consequent of f this permit. Date ►'� APPLICANT S AND WILL COMPLY WITH AL NON OINT Issued by: SOURCE RE Re-roofs Signature o ApplianUConl ac rI D HAZARDOUS ALS DISCLOSURE Type of Roof Will the applicant or future buildi occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Cede,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yeso Will me applicant r future building occupant use eyuipmcnt or devices which If a roof i s installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for'nspection. District? ❑Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety C ,Sections 25505,25533 and 25534.1 understand that if the building S docs not cu tly a a tenant,that it is my responsibility to nouf the occu t of the requirements hi be met ,to issuance of a certificate of Signature of Applicant Date All roof coverings to be Class"B"or better Owner or aut nzcd agent arc INVOICE ' INVOICE INVOICE INVOICE INIOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO PERMIT INVOICE OPERATOR: suew Sec: Twp: Rng: Sub: Blk: Lot: APN , . . . . . . . . : 316.29099. 00 INVOICE DATE. . . . . . : 05/ )9/2007 REFERENCE ID # 07050077 SITE ADDRESS . . . . . : 10336 NORWICH AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER DAN & KAREN RUSSELL ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2446 CONTRACTOR LESLIE HOANG LIC # 23155 COMPANY T D ROOFING ADDRESS 675 TULLY RD CITY/STATE/ZIP . . .-: SAN JOSE, CA 95111 TELEPHONE . . . . . . . . : (403) 892-8872 FEE DESCRIPTION DUE FOR AMOUNT DUE PAID BALANCE --------------------------- ---------------- ---------- ---------- ---------- BLDG PERMIT FEES PRINTING PERMIT 169.56 0. 00 169 .56 SEISMIC FEE RES PRINTING PERMIT 1. 00 0. 00 1 .00 ---------- ---------- ---------- 170 .56 0 .00 170.56 CITY OF ('UPERTINO REROOF CUF TY TING PERMIT APPLICATION FORM APN# Building Address: 10 3 °1 6 Nov w cf` A v,)�_ Owner's Name: P $p Contractoj: O 1^ yl License#: v c� - Contact: Cupertino Business License #: H, ►n 3/5_5 ype of R)of Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles X 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 Will Comply With Cupertino's Tear Off Policy: Job Description: LA.. t- e-� oj,` W �o� S � a �st� � Y) S Residential Commercial ❑ 3J -1:9-, — 4 Fire Zone: Yes ❑ No nfirmed with Planning D�t. if there are any restrictions: Cost of Project: — Type of Construction: Occupancy group. v Qty.if Applicable Fee ID Fee Description Fee Group BPERMFEE .3ldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING Community Development SO 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Building Department JOB ADDRESS: ; cPERMIT V C, to ?>C1 O w \C1G � OWNER'S NAME: S S e PHONE # y o b q S<3 9 GENERAL CONTRACTOR: CDC, V1 q FAX# tj I f I am not using any subcontractors: S `'I O �� Sig nature Date Please check applicable subcontractors and com lete the followin. informa 'on: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date