12080292 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRIiSS: 21081 WHITE FIR Cf CO\rRACTOR:FOUR SEASONS ROOFING PERMIT NO: 12080292
OWNER'S NAME: CHEN TSENG T AND HELEN H PO BOX 1668 DATE ISSUED:08292012
OWNER'S PHONE: 4082557088 SAN JOSE,CA 95109 PHONE NO:(408)27&0330
a— COMMERCIAL//LIICC�rNSSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r, PLUMB PLUMB
License Classpes Lic.H L11 A 100' D1ECH r_ RESIDENTIAL 0r,
/�� .
Contractor f"J p—1 I r.1 C- Date 8' Q 4' 1'L
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF WOOD SHAKE AND INSTALL 13 SOFT CLASS A
(commencing with Section 7000)of Division 3 of the Business&Professions CONIP SHINGLES
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq, Ft Floor Area: Valuation:54500
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35905070.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. -� i, �TG� (a9
p Issued by�: C Date:
Signature & Date
❑ OWNER-BUILDER DECLARATION - RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection.I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicamc Date: —/r—
Business&.Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS T'O RE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS NIATERIAIS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for.by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided Ibr by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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,1 Owner or m ized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
' CONS"rRl1Cr10N LENDING AGENCY
A PILI C\\I'CF,RTI FICAT'ION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITFCI"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS:;to� 1 White fir ct. DATE: 06/27/2012 REVIEWED BY: bobs,
\ APN: BP#: VALUATION: $4,500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: PERM IT TYPE: A
WORK I tear off wood shake and install comp shingles.
SCOPE
Mech. Plan Check Phunb. Plan Cheek Flee. Plat Ch,rck
mech. Pernin Fee: Plunth. Pamir Fee: F:lac. Permu Fee:
Ocher.11rch.Insp. Other Plumb Insp. Other Flee.Imp.
,11e.ch.Insp. Fee: Plumb. lnp. Fee: Flee.hasp.Fee:
NOTE: This estimate does not include jeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District, etc). These fee5 are based on the prelintinan information available and are ath,at atitnae. Contact the Dept for adrtn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) FEE QTY/FEE M1SC ITEMS
Plan Check Fee: $0.00 1,300 s.f. Re roof
Suppl. PC Fee: Q Reg. O OT 0.0 Itrs $0.00 $195.00 IREROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee a Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consnixtion Tax:
Administrwive Fee: O
Work Without Permit? C) Yes (D No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Truncal Docmnernalion Fees: Building or Structure
Strong Motion Fee: IBSEISAIICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IRCBSC $1.00
SUBTOTIA $1.50 $195.00 � ' TOTAGLFEE_:' $196.50
. , -
Revised: 07/01/2012
REROOF PERMIT APPLICATION
COMMUNITY, DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildino(dcuoertino.om
PROJECT ADDRESS APS- O 70
-2 s/
OWNERNAME I PHONE E-MAIL
Se vA T l C P I SS- 08
STREET ADDRESS ��DO CI STATE.21P FAX
P— S i
CONTACT NAAIt. PHONE E->IAIL
e -0 30l
STRELT ADDRESS Sot S CITI'.STAI'E.RIP M\
❑OWNER ❑ Ou'NER-BUILDER ❑ OWNER AGENT Je CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGISFER ❑ DEVELOPER ❑ TEFAM
COPTRACTORNAME LICENSENL'SIBER OR LICENSE 'PE BUS LIC.
COMPASS NAME E-,NAIL FAN
STREET ADDRESS CITY.STATE.21P PHONE
Sot w o$e C $-0
ARCHITECT.ENGI.!NA NIE LICENSE NUMBER BUS.LIC.
COMPANY NAME I E-MAIL - FAX
STREET ADDRESS CITY.STATE.%I P PHONE
VSE OF ❑ SFD or Duplex je Multi-Family ROOF AREA: Ae VALUATION:
STRUCTURE- ❑ Commercial 1 13 S 5'0
aayy
EXISTING ROOF TI'PE: ❑BUILT-UP ROOF ❑ASPHALTSHISGLES l�\OOODSHAKhS 0u'006SHINGLES ❑OTHERISPECIFYI
RCMOVE:REPLACE1'FOS IF v0. PLY\\'OOD ❑ PLY%VD ❑OSB PITCH. ROOF
❑ N .LAA'F.R 'N SS 13T'P 113 A A
//
PROPOSED ROOF TYPE: ❑BUILT-UPNOOF /.ASPHALT SHINGLES ❑\\'OODSIIAKES ❑\\OODSHINGLES 13 OTHER ICC-ES REPORT.
DESCRIPTION OF\1'ORX: ,/Z('
•• Anj Gray
By my signature below.I cenify to each of the following: I am the property o\cner or authorized agent to act on the propemowner's behalf. I hayc read this
application and the information I have provided is cones. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinance and state laws relating to building cons tion. I a• ann repres" I s of Cupertino to enter the above-identified property for inspection purposes,
Signature ol'Applicam/Altent: Date: ao
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
_ If building is associated with a Home Ov%ner'S Association.provide letter PLAIN CHECK TYPE ROUTING SLIP
of approval from HOA. ovtT ER.THE-COUNTER BUILDING PLAN REVIEW
_ Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLAN:CINC PLAN REVIEW
_ P1`0 .copy'of Manufacturer's Installation Specifications. C3 STANDARD ❑ FIRE DEPT
rovide signed copy of Cupertino's Tear-CIT Policy. ❑ OTHER:
Reroof4pp_2011.doc revised 03116/11