07110044 CTTY OF CUPERTINO n � , � T ' � ` `
BUISDING DI'�JSION PE1�1�11T �������� ���������� '
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BUII.DING ADDRESS: PERMIT NO.
10439 PRUNE TREE LN OATES �.00FING 07110044 .
NER'S NAME: �
KWOB KO 5496 BiJTANO PARK DRIVE� 11/08/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHTI'ECT/ENGiNEER: BUILDING PERMIT INFO
T/O EX:3TG SHAKE ROF, RESHT B� E� PLU �
�'+o o LICENSED CONIRACTOR'S DECLARAT[ON � � Job Description
V I hcrcby afG�n Uut I am litenscd unJcr provisions af Chapicr 9 (commcncing - �^ ^ ^. �. _ ^..� ^ _ ^' ^ ^ ^ ^
�Z � wilh Section 7000) of Division 3 of �hc Business md Profcssions Codc, and my licensc is
° t a in fu►1 force and effect. �' ��
� Z Licensc Class 3 Lic. X �'
�'^� F, � Datc - - Con�ractor '
ARCHITECI'S DECLARATION
� o�c < 1 undcrstand my plans shall bc uscd u public rernrda
�qU
4 O y Licensed Prufcssional
y � OWNER-BUILDER DECLARATION
I hcrcby atTirm Ihal 1 am cxcmpt Gum thc Comraaor's Liccnsc Law Ior thc
i p O following reason. (Scction 7031.5, Busincu and Profcssions Catc: Any city or county
K,°, � which rcquires a permit to conswc4 altcr, improvc, dcmolish, or repair any swcwrc
'� Z y priar ta i�s issuancc, also rcquires ihc applicant for such pertnit �o filc a signcd su�emcn�
�_ � �hat hc is liccnscd pursuan� to thc provisions of ihc Conuacwr's Liccnsc Law (Chaptcr 9 Sq. Ft. Floor Area Valuation
y i- $ (commencing wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or
y �.. that he ia exempt therefrom �nd the basis Cor the al►cgcd exemptioa Any violarion oC
Secuon 7031.5 by arry applicant for a pem�it subjccu Uu applicant to a civil penaity of APN Number Oeeupaney Type
not more than five hundrcd dallars (5500).
� I, u owner a[ ttie property, or my cmptoyces with wages u the'v solc compensadon,
will do �hc wark, end ihe stiuctuee is notintended or ofCeced for ss� (Sec.7044. Business Re uired Ins ections
and Professiont Code: The Canuxtor's License Law docs not spply W an owner of Q P
property who 6uilda or improvea thercon, and who does such work himaelf or �hrough his
own employccs, providcd �hat such improvemenu are no[ imm�ded or otfbcrA for sale. If,
however, the building or improvemenl 'u sold within one year of completion, lhe owner-
buitder will have �he burden oC proving Uwt he did noi build or improve tor purpose of
sakJ.
0 I, as owna o[ Ne propeny, am enclusively conuacting arith ticenxd rnnuactors a
consnuct the pmjea (Sec. 7044. Business and ProCcssions Code:)'ILe Contrxtor's Li-
ccnx Law dacs oot apply m an owner of propeny who builds or improves ihereon, and ,
who conuacts Cor such projects with a convactor(s) licensed pursusnt w �hc Convactor's
License Law.
'""� 1 am exempt undu Sec. , B& P C tor Ihis reason
�� Date
WORKER'S COMPENSA'i'[ON DECLARAITON
1 hercby ��m under penalty of perjury one o[ �he follawing declantions:
❑ i hsve and will mainuin s Ceni6cate of Consent w self-insure fw Workcr's Compen-
sation, as provided for by Secdan 3700 af the Iabor Code, for the performance o[ the
work for whicd Nis pertnit is issued.
I havc and will maintain Workcr's Compensation Insurana, as �cquired by Scction
700 of �he Labor Cade, Ca the pedormmce of Ihe work fw which �his permi� is issued. '
My Work C�ompensa�i�on Insurancc carricr and Policy number are:
Cartier.-�d���..v� potiryrto.:7��
CER7'IFICATE OF EXEMP'I'[ON FROM WORKERS'
COMPENSATION [NSURANCE •
(This sectia� necd not bc comple�ed if tde pecmit is far onc hundred doilara (S I00)
or Icss.) '
1 cenify th¢� in thc performance of thc wark for which this permii is issced. I shall no[
n�nploy any person in any man�r so u w bccome subjcct io the Workers Compcnsation
Laws of Califomia Da�c
Applicam
NOTICE 7'O APPL[CAM: If, af�cr making �his CerGGca�c of ExempGon, yau should
baome subjxt to �hc Workcr's Compensatian provisions af thc Lalwr Codc, yau muu
� O foMwith comply with sueh provisions or this pecmit shall be dxmcd mrokcd.
� '"' CONSTRUCiION LENDING AGENCY
[- � [ herchy a[firm that thcre is p consuuction ►cnding agcncy for thc performanix of
p; � ihe work fur which ihis permit is iuued (Scc. 3097, Civ. C.)
W� Q L.endcr's Namc '
� z L.cnder's Address
V 0 I certify ihrt 1 havc read this application and su�e ihat thc above info�madun is
w�'" corten. I agree W comply wiUi all city and county oNinances and sute laws mlating w
� U building consuuction, and hercby authori�e mpresentauvcs of �his ciry to cntcr upon thc
� w ahove-mcnrioncd propcny for inspection purposes
a (Wc) agree w save, indcmnify and kecp humless Ihe Cily of Cupertino against
�� Iiabililiu, judgmcnLS, costs and ezpcnscs which may in any way accrue against said City
V'z in consequence oC the granGng of ihis permi� Date �/�- � �
�"� APPLICANT U STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ?
SOURCE REG NS. c ,,�
f. .� � J���, /� — �—��� Re-roofs �--
Signuure of ApplicanUContraetor �8� T of R�of
HAZARDOUS MA'fERlALS DISCLOSURE }��
�II Il� applicant or futwc building occupant storc or handlc ha•rardous ma�rial
icfined by Ihe Cupenino Municipal Code. Chapmr 9.12, and the Hcal�h and Safcty
.1c. Section 25532(a)? � All roofs :�hall be inspected prior to any roofing material being installed.
❑ Ya
wll the applicant or futurc building occupant use eyuipment or devices which
If a roof i: installed without first obtaining an inspection, I agree to remove
emii harardous air conuminm�s as dcfincd by Uic Bay Arca Air Quslity Managcmcni all new m. �terials for inspection.
��s�;���
❑ Ycs �u �
T
1 havc rcad the hvaedous maicrials requirements under Chap�cr 6.95 of ihc Gli[or- _=�
nia HcaIN & Safety Code, Sections 25505, 25533 and 25534.1 undcrstand thu i! Uu building `l —�� U �
docs rrenUy havc a mnan4 �8� it is my responsibility w noufy �hc occupset M thc
rcyu' whichmus� �� �o�a�u��orac�r�a�oro�����r. Signature �fApplicant Date
�� Y � All roof coverings to be Class "B" or better
Owncr or autharizcd cnl ���
CITY OF �.UPERTINO
3 ITEMS OF 10 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 31633080.00
DATE ISSUED.......: 11/08/2007
RECEIPT #.........: BS000003197
REFERENCE ID # ...: 07110044
SITE ADDRESS .....: 10439 PRUNE TREE LN
SUBDIVISION .......
CITY .............. CUFERTINO
IMPACT AREA .......
OWNER ............. KWCB KO
ADDRESS ......... 10439 PRUNE TREE LN
CITY/STATE/ZIP ...: CUFERTINO, CA 95050
RECEIVED FROM ....: EDinARD A GREGORY
CONTRACTOR .......: THCMA5 OATES LIC # 26344
COMPANY ..........: OA'I'ES ROOFING
ADDRESS ..........: 54�6 BUTANO PARK DRIVE
CITY/STATE/ZIP ...: FRf;MONT, CA 94538
TELEPHONE ........: (5�0)750
FEE ID UNIT QUANTITY ��'IOUNT PD-TO-DT THIS REC NEW BAL
---------- --�-------- ----------
BPERMFEE VALUATION 9,200.00 169.56 0.00 169.56 0.00
BSEISMICRE VALUATION 9,200.00 1.00 0.00 1.00 0.00
BUSLIC FLAT RATE 1.00 107.00 0.00 107.00 _____0_00
----------- ---------- ---------- -
TOTAL PERMIT : 277.56 0.00 277.56 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----------
CREDIT CARD 556.60 MC
TOTAL RECEIPT : 556.60
rn �cui.� 7NI 53�I112l35 11W'J3d t�`J'jLLiGSLt�L b L�b►� LddG/tik9/ L l
. o7��c�o�-�
CITY OF I�UPERTINO
����j REi�QOF
CUPER`TIN�3 PERMIT APPI,ICATION FORM
APN # / ,,1 Date: �/_ � _ G � �
�6 � � � �d �, �V
Building Address: ��(
� �l' ��� e� ���
Phone #: � 7 ��
Owner's Name• I // � y�8� �� --
� f��.
� �, �i �r ��c �,- � f' License # � `�. yO �
Contractor: Y `� � �
c `'��' s ��� �� ���� ✓~� C � � 3 � Cupertino Business License :
Conta ct_ J
� �,,.1 �sr �P S
Type of Itoof Covering:
Existing: Proposed:
❑ Built-Up roof
0 Built-Up Roof �{, Asphalt Shingles � 5 y�� �/ S� �✓'
❑ Asphalt Shingles ❑ W ood Shakes
j'� Wood Shakes
❑ Wood Shingles
❑ Wood Shingles ecif
❑ Other (Specify) ❑ Other (Sp y)
Nu�nber of existing coverings I
❑ Provide I.C.B.O. Report #
� To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With Cupertino's Tear Off Polic :
Job Description: /� � � -z��7' � � -�J�� �� l� 25 Y�,�- C�� ._ 02 �
/ ,L�x � S `l�.1 S G, � �� 14�� �� - /f� , s��t� ! � �S� ,
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D�t. if
there are any restrictions:
T e of Const�uction: Occupancy grou
Cost of Project: Yl� � \2 �
�/Z G'1,� ' _
Qty. if Fee Description Fee Group
Applicable Fee ID BUILDING
BPERIVIFEE Bldg Permit Fees
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
Community Development
F ,'�..,_ � 10300 Torre Avenue
�� ; i��,: ; Cupertino CA 95014
_ Telephone (408) 777-3228
, �CITY OF Fax (408) 777-3333
CUPEI�TINO
Buildin� De artment
JOB ADDRESS: /� C/ � j ��� e ���� ��� PERMIT #�� � �� ��
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: ,�1 ' v . i � � FAX # � � - � �.� - c� �.��
� �� �
I am not using any subcontractors: ,+ k� Ld,�Qi4� �. � ' �� ����
Sigr �ature Date
Please check a licable subcontractors and com l��te the followin information:
SUBCONTRACTOR BUSINI:SS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Fini.shing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
� Roo� ���5 � r:�. � ;� �
Septic Tank
Sheet Metal
Sheet Rock
Tile
�
/1-,�-� �
Owner/Contractor Signature � Date