10070071CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 20884 ALVES DR I SYS TRACTOR: WESTERN ROOFING EMS I PERMIT NO: 10070071 I
OWNER'S NAME: BANDLEY SEIKO 11321, WHITE OAKS RD I DATE ISSUED: 07/09/2010 1
"VNER'S PHONE: 4084462375
L-1 LICENSED CONTRACTOR'S DECLARATION
License Class Lic.##
Contractor
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I 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 building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Date
l� OWNER -BUILDER DECLARATION
i -by affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. I, 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 & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
3. 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 as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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 building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
of this permit. Additionally, the applicant understands and will comply with
L, .. -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
CAMPBELL, CA 95008
PHONE NO: (831)278-1837
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
TEA 20FF 3 LAYERS OF ROOFING,FILL SHEATING AS
NEE 3ED,DUPONT ROOF LLINER UNDERLAYMENT,METAL SHAKE
ROOFING SYSTEM PER ER 5626
Sq. 1't Floor Area: 0 1 Valuation: $14000
APN Number: 32631010.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issu :d by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
insta led without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I hale read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safely Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
cont,.minants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Heal :h & Safety Code, Sections 25505, 25533, and 25534.
Own !r or authorized agent:
Date:,
CONSTRUCTION LENDING AGENCY
I herr by affirm that there is a construction lending agency for the performance of work's
for wiich this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I and :rstand my plans shall be used as public records.
Licer sed Professional
no
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: LDt:
APN ........: 32631010.00
DATE ISSUED.......: 07/09/2010
RECEIPT #.........: 990000)0241
REFERENCE ID # ...: 10070071
SITE ADDRESS .....: 20884 .ELVES DR
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER ............: BANDLEY SEIKO
ADDRESS 20884 .ELVES DR
CITY/STATE/ZIP ...: CUPERTINO CA,
OPERATOR: suew
COPY # : 1
95014-1826
RECEIVED FROM ....: Western Roofing Syst
CONTRACTOR .......: MICHAE:'j LUNNEBORG LIC # 25896
COMPANY WESTERN ROOFING SYSTEMS
ADDRESS ..........: 1328 W:lITE OAKS RD
CITY/STATE/ZIP ...: CAMPBE:�L, CA 95008
TELEPHONE (831)278-1837
FEE ID UNIT
----------
QUANTITY
AMOU]JT
PD -TO -DT
THIS REC
NEW BAL
-------------
OLBCBSC VALUATION
----------
14,000.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
OLREROOF SQUARES
23.00
239.00
0.00
299.00
0.00
OLSEISM VALUATION
14,000.00
1.40
0.00
1.40
0.00
TOTAL PERMIT
----------
301.40
----------
0.00
----------
301.40
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
301.40
---------------
301.40
VOICE ID DESCRIPTION
-------- ----------------------------
601 ROOF TEAR OFF
REFERENCE NUMBER
--------------------
VS,TA5BC8A922
VOICE ID DESCRIPTION
-------- ----------------------------
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS 605 FINAL REROOF