03050030 CITY OF CUPERTINO
BUILDING DIVISION PERMIT TRACTOR INk'U IA.T7UN
,
BDILDINcnoofpss: ROBERT BARNES CONSTRUCTION Pp ""D03050030
WTrT4 A17
OWNER'S NAME: 1194 LICK AVE PE"ffn8/2003
ENNINGSEN D
NE: (408) 971-3955 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDGO ELECTO PLUMB MISCH
;j o a LICENSED CONTRACTOR'S DECLARATION MJob Description
1 hereby aMo.Nat I am licensed yyyyyynJJJJJJyyyyyy��{��{pro .At. s of Ch Pic
9(commencing
wiNSccdo 70(IU)of Divimm3 of me Bu ke'and Profcuions Code.and myliccna is
in full force ae1dVOL REROOF
jnZ Dacnac Cur
Z Dames CuntrmWmWQ� Aa-rykfla l[v
3 ARCHllImusSEFpCA meet&�()N,'`CVLTrw"'
'y6 l \ �pnde un my plhell be used u public rtcnNs
Lk na Pmmamn. SEP 0 2003
to OWNER-BUILDER DECLARATION
F 1 hctehy oRrm that 1 am exempt from the Comracmr'r License Law for the
sod, follnwingmason.(Section7(01.5,BualneuandPrefesalomCale:Anycityorcounty BUILDING
which requires a permit to consumer,alter,improve,demolish.ar repair any mructum BUILDING
prior to its issuance.also requires the applicant for such permino rile a signed stm meni
that he is licensed pursuant to the provisions of the Common's Llcenm Lew(Chapter 9 Sq.Ft.Floor Area $8"tion
y�$ (commencing with Section 7(100)of Division 3 of Ne Business and Pmressimu Code)or
Out he is exempt Ihemfmm and the hues for the almgad evmpd..Any violation of
Section 703 L5 by my applicant for a permit subjects Ne applicant m a civil penalty of 31MVNHjftcr0 0 Occupancy Type
not foam Nan five hundred dollars($500).
❑1.u owner of Ne property or my employees with wage u Heir vele compenation.
will do Ne wort,and meswmum isootinunded or afferent foralc(Sec.701/,Business —
and Professions Cade:The Comm roes License Law does ret apply man owner of 307 — INSULA 1-UIN d Inspections
property who builds or balloons themon,and who doessuch work himself orNrough Ms
own employees,provided drumch impronmmts are not intended oroffertd forale.If. 601 — ROOF TEAR OFF
however.the building or improvement is sold within on year of completion,Ne Owner.
Wilde'
will haw Me burden of proving that he did not build or Improve for purpose of 602 - ROOF PLYWOOD NAIL
ale')' 603 - ROOF BATTENS
0 I.u owner of the property am exclusively convecting with licensed contractors to
construct the project(Sec.70aa,Busirs.and Rofesdam Cade:)The Canuscter'a Li- 604 — ROOF IN-PROGRESS
cease Law does not apply to an owner of property who builds or improves Desmon.and,
who contracts for such projects with a conuanmr(O licensed pursuam in me Contrhim's
License Law.
O l am escrept under sm. .B&P C fa Nis ninon
Owner Date
WORKER'S COMPENSATION DECLARATION
I thereby af10m under partly of perjury one of the following declantlons:
1 hew and will mainuin a Certificae of COnaenl l0 self-inane for Wakci sCompcn-
seOon,u provided for by Section 3700 of me Inbar Code.for me performance of the
work,par which this permit is issued.
0 1 ban and will maintain WarkeM1 mu Compensation Insuce, required by Section
3700 of Me Mbar Code,for the performance of the week for which Nis permit is issued.
arker's Compensation insurance varier Pall number she:
er. ?f Np Poli .:
CERT CATEOFFFJ(EMPTI0 FROM K
COMPENSATION INSURANCE
(Thu section need not be completed if de Permit 4 farone hundrtddollar(SIOO)
M I=)
1 certify that in me performance of Me work for which this permit IS loved,I shall nut
employ any person in my manner An a At become subject in the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to me Worker's Compensation provisions of me Labor Code,you must
,Z foMwiN comply with such provisions or this permit shall be deemed ranked,
z O CONS rRUCT1pN LENDING AGENCY
I hcrchy Ifirm that Nene is a comuucto.lending agency fns Ne perfurmonce of
Q'.7 me work for which%is Permit is issued(Sec.3097,Civ.C.)
{y]Q L rAme3 Name
jz Lender's Add.
V Q 1 certify mat 1 have read this city
and county
and sum Nu Nc about Information i1.
n
Em*
com:ct.I ague m comply with all city and coumy oNinanen and state laws relating m
OI` Wilding construction,and hereby sumorie,Rprlammim of this city to enter upnn de
Lk7 above-mentioned prepcny for impeNon Purposes
py (We)agree to saw,indemnify and keep harmless the City of Cupertino against
h Ilsbilides.judSomms,cofu and expenses which may In my way a come ASA rat said Cdy 1�
U z in consequence of me grmung of this Permit. J
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU RgCU�A ONS.
r-66u� \/e59 i Re-roofs
urto(Applic 11Canuacmr v' Use¢
t t HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant atom or handle hvandous material
As dcOned by Oe Cupertino Municipal Code,Chapter 9.17.and the Health and Safety
Code.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea )Iro
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ad,husrdnus air mmarnmanu u defined by the Bay Arta Air Quality Management all new materials for inspection.
DuuMt7
0 Yes KN.
Hove read thehuamnusmatedais quimmcnuun@r Chepmr6.95ofine Califor.
nix Heslthh Safety Cab.Sccum2S505.25533aM255M.l understand Matifde building 3
rg-o
dors not cumm nly how a mnam that h is my responsibility notify the occupant of me J
pdormissur¢eora Ccnifmateor Oce Signature of Applicant 'Date
l
Owner or authadsd.gem
�
� All roof coverings to be Class "B"or better
Dom
Community Development Department
Building Division
yi
City of Cupertino
"- 10300 Torre Avenue
CITY OFTelephone: (408)777-3228
C U p E kT!]N O Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
• 2) In-progress inspection approval.,
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
IMPORTANT:
1. Flat roofs must have a minimum of l/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: ()W&?L 6_wl"56-ni
Job Site Address: IC)F `7 Noewlcd 11VE
P9 df-
Roofing Company Name:
A plicant's Signature: Date: J�'Y O 3
Greg eel
Building Official
Revised 1/30/03
Printed an Recycled Paper
y CITY OF CUPERTINO
REROOF 3
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
316 'a 9-o9r s-6,0 3
Building Address:
10?V& jerV CN
Owner's Name: Phone #: y(�_�f 981 y
HENAIIA,,6 s r/1l
C ntractor: Phone #: 056,713_37?e License#:
B ES C0Avre,1GTlov
C ntact: 5 Phone#: Cupertino Business License#:
Bfli',vel(78. 313- S��
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Bf Asphalt Shingles V' Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:p
fe-R�'� w Cth�5t4
Residential Commercial ❑
FireneYes ❑ No ❑ Confirmed with Planning Det. if
there
of Pr oj ehere are tnp
ctions: 6J
� Type of Const Occ y gr p:
Qty. if
A le Fee ID . Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
4
L
� g7 �o
CITY OF CUPERTINO
�m 2 of 2 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . . 31629095 . 00
DATE ISSUED. . . . . . . : 05/08/2003
RECEIPT # . . . . . . . . . : 21812
REFERENCE ID # . . . : 03050030
SITE ADDRESS . . . . . : 10346 NORWICH AV
SUBDIVISION . . . . . .
CITYCUPERTINO
. . . . . . . . . . . . . .
IMPACT AREA . . . . . .
OWNER HENNINGSEN DARRELL E
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2446
RECEIVED FROM . . . . : ROBERT BARNES CONSTR
CONTRACTOR . . . . . . . : ROBERT BARNES LIC # 24437
COMPANY . . . . . . . . . . : ROBERT BARNES CONSTRUCTION
ADDRESS . . . . . . . . . . : 1194 LICK AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95110
TELEPHONE . . . . . . . . : (408) 971-3955
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ------- --- ------- --- ---- ------
BPERMFEE VALUATION 8, 000 . 00 137 . 00 0 . 00 137 . 00 0 . 00
BSEISMICRE VALUATION 8, 000 . 00 0 . 80 0 . 00 0 . 80 0 . 00
---------- ---------- ------- --- ----------
TOTAL PERMIT 137 . 80 0 . 00 137 . 80 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ - -----------------
CHECK 433 . 15 1166
TOTAL RECEIPT 433 . 15
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--305=== FRAME ==307=== INSULATION=====_____________
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS