11090073 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10138 MYER PL CONTRACTOR:TIP-TOP ROOFING PERMIT NO: 11090073
OWNER'S NAME: HIGDON VIRGIL L AND MARY D TRU 1160 NADINE DR DATE ISSUED:09/12/2011
-VNER'S PHONE: 4084469194 CAMPBELL,CA 95008 PHONE NO:(408)370-6425
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# 91'd 6 0
�/ MECH RESIDENTIAL COMMERCIAL
Contractor 141170Z 'Ac"'cz- Date
r �
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF TEAR OFF TILE ROOF&REPLACE WITH COMP
(commencing with Section 7000)of Division 3 of the Business&Professions SHINGLES,EXISTING SHEATHING STAYS CLASS A 28SQFT
Code and that my license is in full force and effect.
I 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:$15380
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:31623045.00 Occupancy Type:
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 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. Issue y: Date e
Signature i 9 Z �'��' Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I 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.
1,as owner of the property,or my employees with wages as their sole compensation, , J 1_01 /
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS 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 for 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 I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I 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,I Owner a horized nt:
become subject to the Worker's Compensation provisions of the Labor Code,I must i t2Ae2i,o�j Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION 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.I 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,
c fs,and expenses which may accrue against said City in consequence of the
ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
....,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
REROOF PERMIT APPLICATION --
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTIN4 (408)777-3228• FAX(408)777-3333 • building aacupertino.org
PROJECT ADDRESS 3 8 &V P,0e - API'# �p D
OWNER NAME ///¢� T/ �Oof PHO 2 �'Yo�`/-QE-MAIL
TREET
SADDRESS CITY, STATE,ZIP b / FAX
APPLICANT NA31
E-MAIL
ME
STREET ADDRESS ` r�Oi�C ap crlY,s TE ziP FAx
C ��ps�t� <::;oq
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME � Z /��Ol G.y LICEmAy ; O -7 LICEN I� BUS.LIC.#
COMNAME /.-W NA /�`�•v �G� ' E-MAIL �Io 5 FAX
I
STREET ADDRESS �,� CITY,STATE,ZIP PHONE
�R /N0� G3��S-�s3El��
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OFor Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial Z 8: 1--. 3,_-5,d ADO
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ffYESIF NO. PLYWOOD h ❑ PLYWD ErOSB PITCH ROOF
❑NO #LAYERS: ��THICKNESS: 115/8" TYPE: ElX 12 CLASS: A
PROPOSED ROOF TYPE: E3BUMT-UP ROOF LJ ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTAER ICC-ES REPORT#
DESCRIPTION OF WORK e04e �� .� �✓/(, S //I j�R�C �D C�j
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ' g construction. I authorize.representatives of Cupertino to enter the above-id 'feed properC,-for inspection purposes.
Signature ofApplicant/Agent . a Z Date:
SUPPLEMENTAL INFORMATION REQUIRED _ -
--p – ~
If building is associated with a Home Owner's Association,provide letter `ELATrtlr-usa yr -OILTI>NsLI>agg '
of approval from HOA.
Provide Planning approval to verify if there any restrictions. 9M
Provide copy of Manufacturer's Installation Specifications.
_ rrovide signed copy of Cupertino's Tear-Off Policy. . . —`
ReroofApp_2011.doc revised 03/02/11