10070163 CITY OF CUPERTI vO BUILDING PERMIT
BUILDING ADDRESS: 1113 STAFFORD DR CONTRACTOR:R E ROOFING& PERMIT NO: 10070163
CONSTRUCTION INC
"WNER'S NAME: JACK MELNICK 15230 CLYDELLE AVE DATE ISSUED:07/23/2010
OWNER'S PHONE: 4089739367 SAN JOSE,CA 95032 PHONE NO:(408)626-9320
❑ /LICENSED CONTRACTOR'S DECLAcR�ATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIALE]
License Class l� � Lic.# -7215 ' I RE-ROOF REMOVE EXISTING 1 LAYER OF WOOD
SHAKE,
Contractor L �iUU� I�(•r C`�Date I`J INSTALL NEW 1/2" CDX,30#FELT& LIGHTWEIGHT TILE
I hereby affirm that I am licensed under the provisions of Chapter 9 CLASS A 35 SQUARES
(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:
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. Sq.Ft Floor Area: Valuation:$24000
I 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
APN Number:36206009.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INS ECTION.
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 Issued by: l Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18(p2,e >A4,_� A
Z RE-ROOFS:
qn Date r I(� All roofs shall be inspected prior to any roofing material being installed.If a roof is
- _ installed wjthodt first_ tai an inspection,I agree to remove all new materials for
inspech.04. '
❑ OWNER-BUILDER DECLARATION
Signa i�ure o(Applicam,, Date: l l u
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: L ROO OVER-ING
ALS TO BEC ASS"A"OR BETTER
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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compljancew.�th the Cupertino Municipal Code,Chapte 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Hea) &S e Co Sec 'ons 25505, 533,and 2)5534.
Section 3700 of the Labor Code,for the performance of the work for which this t 2 j
permit is issued. Owner or authorize gent' Date:
I 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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
mnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: -3 A�ruby _ PERMIT# VQ 6
OWNER'S NAME: �A'�i� l:�l. ►4 l CCK- PH NE# +o f - � — x'136
GENERAL CONTRACTOR: � L Ro Jf-1 N 5 CcnJ st>u•�l USINESS LICENSE#
ADDRESS: 2-3U Lot %Lt.iAv CITY/ZIPCODE: 2
*Our municipal code requires all businesses working it the city to have a City of Cupertino usiness license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR L SiBE44N_TF:A5T HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. t." ~ -Z-3 I J
I am not using any subcontr,ctors:
;nature Date
Please check applicable subcontractors and complete the following information:
j/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum/Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMI'^ RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Bl].: Lot :
APN . . . . . . . . : 36206009. 00
DATE ISSUED. . . . . . . : 07,23/2010
RECEIPT # . . . . . . . . . : BS000010950
REFERENCE ID # . . . : 10070163
SITE ADDRESS . . . . . : 11:_3 STAFFORD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JACK MELNICK
ADDRESS . . . . . . . . . . : 11:_3 STAFFORD DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4911
RECEIVED FROM . . . . : R H ROOFING CO
CONTRACTOR . . . . . . . : PROCTOR, PAUL LIC # 20615
COMPANY . . . . . . . . . . : R I; ROOFING & CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 15230 CLYDELLE AVE
CITY/STATE/ZIP . . . : SAI1 JOSE, CA 95032
TELEPHONE . . . . . . . . : (408) 626-9320
FEE ID UNIT QUANTITY liMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
1BCBSC VALUATION 24, 000 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 24, 000 . 00 2 .40 0 . 00 2 .40 0 . 00
1REROOFRES SQ FEET 35 . 00 455 . 00 0 . 00 455 . 00 0 . 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 458 .40 0 . 00 458 .40 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 458 .40 2513
---------------
TOTAL RECEIPT 458 .40
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
its ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$24,000
'PERMIT TYPE: Minor Building Permit PL AN CHECK TYPE: Re-roof
PRIMARY TOTAL APPLICATION
USE: SFD or Duplex ROOF A]1EA: 3,500 S f TYPE:
as
00
3 �
FI;E ID
1 RERI)OFFRES
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (1w Resolution 0.9-051 I f i/1:'09) FE_E QTY/FEE MISC ITEMS
Permit Fee: $455.00
F
>x ,
Work Without Permit? Q Yes E) No $0.00
Strong, Motion Fee: IBSEISMICR 12.40 Select an Administrative Item
Bld = Stds Commission Fee: 1BCBSC 11.00
SUBTOTALS: $458.40 $0.00 TOTAL FEE: $458.40
Revised: 6/30/2010
CITY OF
CITY OF CUPERTINO
RE ROOF
CUPERTINO PERMIT APPLICATION
le�7 7DA!?,,
APN # Dip 00 • &J Date: 2-3110
Building Address:
Owner's Name: �J, aCK_ 0161 n4JL_ Phone #:
-
HOA: Yes ❑ No If es, provide letter from HOA L. j� q1 � - 9V
Contractor: Phone #:
�. U(!l� ��!1� i C U1rJ �'�1ZUIC.Tl u"i NC
Fax#: 40
Cupertino Business License #: Zn Contractor License #:
Type of hoof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) �A, Other (Specify) �-
Number of existing coverings 1 ❑ Provide I.C.C.E.S. Report#
ATo be Removed ❑ Provide Mfgr. Installation Specs.
Job Description:' ; , Lel ini 1 L A-\4 oti_. W vVY1 i N�TA-v L
`12" Gh�,,
5 SO LAIrt
Residential ❑ Commercial ❑
Green Building: Please complete relevant portion of the Confirmed with-Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet inclex.
Valuation: W
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 02/05/09
M.Indoor Mr Qualfty and Finishes
1 IAQ/Health pts y=eyes
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health is es 0
. P Y=Y
&the bxft4qq31AQ/Health pts y=yes p
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywood.for Interior Uses 1 IAQ/Health pts y=yes 0
4IAQ/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes D
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
N.Flooring
1.Select FSC Certified Wood Flooring-- B Resource pts yges 0 —
4.le. ,. - 4 Resource is
•- _ P y--yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
S.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
Total Points Available: 140 130 57
�.. -__.
Total Points Project Received: ,� 1 01 0 0
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