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B-2017-1191CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22360 PALM AVE CUPERTINO, CA 95014-2710 (357 04 055) CONTRACTOR: HOMEOWNER PERMIT NO: B-2017-1191 BUILDER OWNER'S NAME: MALISIC MMADIN TRUSTEE & ET AL DATE ISSUED: 07/21/2017 OWNER'S PHONE: 408-217-9599 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor HOMEOWNER BUILDER Date XBLDG —ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — MECH X RESIDENTIAL — COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: REROOF; TEAR OFF; COMP SHINGLES (45 SQ) 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. 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 permit is issued. Sq. Ft Floor Area: Valuation: $15000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 357 04 055 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting this permit. Additionally, the applicant understands and willl comply with all ll non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION° Signature Date 7121/2017 Issued by: Abby A ende OWNER -BUILDER DECLARATION Date: 07/21/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. /safe (Sec.7044, Business & Professions Code) 6 s (,, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 7121/2017 1 hereby affirm under penalty of perjury one of the following three declarations: t. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE / ! I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the ection 3700 ofthe Labor Code, for the performance ofthe work for which this Kl-'p'S,erniit California Health & Safety Code, Sections 25505,25533, and 25534. I will is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Ow.ner o/� r authorized agent: APPLICANT ANT RTIFI ATION <Date: 7/21/2017 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non- oint source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section .1 .R I understand my plans shall be used as public records. .40 7 / � Signature Date 7 1 1 Licensed Professional 1" ,, RERO®F PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTENt7 (408) 777-3228 • FAX (408) 777-3333 • build ingp_cupertino.org PROJECT ADDRESSlL / j9,�, 2L7 �N, � 7T-04- OWNERNAME,O :G^�r ryPHONESTREET ADDRESS � ,,{� / t/ Au CITY, STATE, ZIP n � ?Ay FAX CONTACT NAME PHONE STREET ADDRESS . ; C E, ZIP VdINTER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOORRA,G•ENT ❑ ARCHITECT ❑ ENGLNEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC. COMPANY NAME E-MAIL FAX STREETADDRESS CITY, STATE, ZIP PHONE ARCHrrECT/EINTGI NTEER NAME LICENSE NUMBER BUS. LIC. r COMPANY NAME E_MpIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ,� USE OF LV<D or Duplex ❑ Multi -Family STRUCTURE: ❑ Commercial ROOFAREA- VALUATION -000 EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) REMOVE/REPLACE 11 YES El IFNO, r LAYERS: PLYWOOD ❑ w, ❑ THICKNESS: ❑ 5/S" PLYWD ❑ OSB TYPE: ❑ CDX PITCH:ROOF ' 12 CLASS: A PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES WOOD SHINGLES ❑ OTHER ICC -ES REPORT n DESCRIPTION OF WORK: Qyi 'Me 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 bave read this application and the infonnation 1 h e provide s torr ct. I have ad the De ption of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws rola ' g $�I' o s tiUau Aer tCu ertino to enter the above -1 d fed prop for inspe oses. Signature ofApplicant/Agent Date: e� SUPPLEMENTAL INFORMATION REQUIRED _ If building is associated With a Home Owner's Association, provide letter of approval from HOA. Provide Planning approval to verify if there any restrictions. Provide copy of Manufacturer's Installation Specifications. Provide signed copy of Cupertino's Tear -Off Policy. OFFICE USE oi.Li 111 --AN CHECK.T1T9 xoUil.rc si P . , `❑ ovER TLS couNTEt - ❑aPREss : ❑ 'sTANnaRn ❑ BLILDINGPLANREVIEYv 1=l riIvkNGPnN xENw ❑ FIitEDEPT ; OTTER ReroofApp 2011.doc revised 03116111 CUPERTIN© REROOF TEAR -OFF POLICY COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • building(c�cupertino.org PROJECT ADDRESS / *°S l�J�� /t /� A f _ APN # c. c O WNER NAMEA.� 4A i cry I L��. PHO STREET ADDRESSCITY, STATE, ZII FAX7:0�/ CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP i' PHONE I UNDERSTAND AND AGREE TO THE FOLLOWING: 1. The re -roof project shall comply with all applicable provisions of the 2016 California Codes. 2. An inspection request can be scheduled up to one business day before the requested inspection date. To schedule inspections call (408) 777-3228 from 7:30-3:30pm (Mon-Thurs) or 7:30-2:30pm (Friday) to schedule inspection. For Tear -Off and Nailing Inspections, you must also call on the day of the inspection only after that phase of the work is completed. The building inspector will be out to the job site within one hour. The hours for this service are: 7:30-10:30am and 12:30-3:30 (Mon-Thurs) and 7:30-10:30am and 12:30-2:30 (Friday). Final Inspections will be given a two hour window. 3. Tear -Off Inspection is required. Any and all dry -rotted wood shall be replaced prior to this inspection. Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either completely knocked -down or removed prior to this inspection. 4. If plywood is installed, a plywood Nailing Inspection is required. 5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the building inspector. Any roofing which is applied without first obtaining an approved inspection will require the removal of all new material down to the sheathing so a proper inspection can be performed. 6. A Final Inspection and approval shall be obtained from the building inspector when the re -roofing is completed. To receive a final sign -off, the following items will be verified: a. Flat roofs shall have a minimum of I/" per foot of slope and demonstrate there is no ponding. b. Listings from approved testing agencies for all pre -manufactured products used shall be available on-site to review at the time of the inspection. c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed. 7. NOTE: If you call for a tear -off or plywood nailing inspection and the work is not complete, you will be charged a re -inspection fee. The re -inspection fee shall be paid before another inspection can be scheduled. By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act on the property owner's behalf. I understand and agree to comply with the re -roof policy stated above. I also understand that smoke detectors and carbo4n., xide etecto.17,� Nre;red to installed in accordance wit Sectioons jR314 aid R315 of the 2016 California Reside Signature o `'��C g f Applicant/Agent: Date: ReroofPolicy 2014.doc revised 0610117 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(L.cupertino.oro Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS r/'I �Gy`- /� � _ APN � BP# OWNER NAME M,(� L� 1� _ OWNER ADDRESS DESCRIPTION OF We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) CAAunderstand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. AUderstand building permits are not required to be signed by property owners unless they are responsible for econstructio nn and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may rot ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. *me nderstand Contractors are required by law to be licensed and bonded in California and to list their license on permits and contracts. �erstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. I understand if !I am considered an "employer" under state and federal law, I must register with the state and lede I government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemplo ymentt compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family resid tial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by license suf contractors and the number of structures does not exceed four within any calendar year, or all of the work iWnarnu e under contract with a licensed general building Contractor. erstand as anOwner-Builder if I sell the property for which this permit is issued, I may be held liable for aial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OWne7Bitildel FOrn2 2010.doc revised 04114110 I understand I may obtain more information regarding my obligations as an "employer" from the Internal Rea ue Service, the United States Small Business Administration, the California -Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed . I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. ee that, as the party legally and financially responsible for this proposed construction activity, I will abide Micable laws and requirements that govern Owner -Builders as well as employers. ' 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the i rmation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm th t there is a c nstruction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name ender Addres%;����' ( t Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: ------------------------------- ----------------------------------------------------------------- --------------------------------------------- (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm1 2010.doc revised 04114110