12070051 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21363 DEXTER DR CONTRACTOR:SIMON SAYS ROOFING PERMIT NO: 12070051
OWNER'S NAME: ILLOWSKY DANIEL H AND BARBARA 3012 BECKLEY DR DATE ISSUED:07/092012
OWNER'S PHONE: 4084469258 SAN JOSE,CA 95135 PHONE NO:(408)531-9700
❑ LICENSED CONTRACTOR'S DECLARATION 30B DESCRIPTION: RESIDENTIAL 11 'ONIMERCIALU
License Class L`3`( Lic.N 7gg9q RE-ROOF 28 SQ- REMOVE WOODSHAKE INSTALL 30LB
^Ar FELT
Contractor o f S ab0F,+ Date 7 'C/ 't 2' 1/2 PLYWOOD 30YR COMP CLASS A
I hereby affirm that I am licensed under We provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally 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 whichthis permit is issued. Sq.Ft Floor Area: Valualion:$12000
1 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:32641086.00 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 DAY MLA CALLED INSP TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, /�
costs,and expenses which may accrue against said City inconsequence of the "I
Dale:
granting of this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
���777 RF.-ROOFS:
Signature Daley All roofs shall be inspected prior to any roofing material berg installed.Ira roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION 9 7 _ g- 1.2—
Signature of Applicant: �`� - Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BF.'ITER
1,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 MA-rERIA S DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapler 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safely 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 1 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 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for die,performance of the work for which this Owner or authorized agent: - Dale:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCf10N LENDING AGENCY
become subject to the Worker's Compensation provisions ofthe 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 stale 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
upon the above mentioned property for inspecfion purposes.(We)agree to save ARCIIITF:(T'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 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 Dale
i
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
CUPERTINO
(408)777-3228• FAX(408)777-3333•building(&cuoertino.org
PROJECT ADDRESS 21 102 de,,-L6(L aa-
APNH
OWNER NAME J / 1CPHONE E-MAIL
STREET ADDRESS 7-1363 (� (•P/t. �/� CITY A TE 21P Al0 C FAX
CONTRACTOR NAME 1✓t'Q.I` ; 7,y O / . LICENSE 1��tiil�rtrt LICENSE TYPE BUS.LIC.9
COMPANY NAME F ^E-MAIL Ci PQ FAX
CI AAA At OD 111
STREETADDRESS v 9� ( 3S f CITY TATE,ZIP P ONEyop) S ,I _9766
?a/1 BLS �4�1Eac e c
UNDERSTAND AND 'AGREE TO THEEFOtLOWING:
SJa., . �
1. The re-roof pr'6ject shallRcomplyis gith all applicable provisions of the 2010 California Codes.
2. An inspection request c5ri%etscheduled up to the da�IWMFf the inspection date. Please.calll(408)777-
3228 from 7:30 - 3:30pm (Mon-Thurs)•or 7:30 - 2:30pm (Friday)tc_scheduld'the next day inspection.t;,
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 available within one hour. Progress
and Final Inspections will be given a two hour window. I, j
3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replace'pnorito•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.
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4. If plywood is installed, a plywood Nailing,Inspection is required.
J '"' L_ J�uVZ I
5. Roofing shal Foot be appUed withoutArst obtaining all#prio>;inspection and written approvals from the
building inspector. Anyirodffng,which is applied without f rst'-obtaining an approved inspection will
require the removal of all new materiali,4ow to the sheathing so a proper inspection can be performed.
6. Progress Inspection is required when approximdtelyjo%o ofroof co ering is installed.
7. A Final Inspection and approval shall be obtained from the butlding;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 Y<" 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.
8. 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 of$126.00. 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: 1 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 carbon monoxide detectors are required to be installed in accordance with Sections R314 and R315 of
the 2010 California Residential Code.
Signature of Applicant/Agent: Ign 6n, Date: ` c?_ Z—
. Rrrou/Polir_c_1011 doc,ei sed 03116111
-1k
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
.. 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
C U PERTI NO (408)777-3228• FAX(408)777-3333•buildino(dcuoertino.oro ��W
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PROJECT ADDRESS , 3(x,3 `(V G Kp e/JE& AAPNd 3 LC ,S_`
OWNER NANIE 1 [L 1
PHONE
STREET ADDRESS -7 `��� 1 eAEQ _I /J CRY, STAT. E ^ I CA FAx
CONTACT N.VAE L (� (,'tIL PHONE Gr'�R E-AIAIL
STREET ADDRESS CRY.STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACroR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTaiCTPR NA M1IE I f LICENS LICENSE TEPE BUS LIC.n
S7 / IMOII C3-
COM NY NAME EMAIL FAX
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ST ET.Z RESS^�`��G Ct� CRY, ATE.ZI�� �j-I r�r PHONI(u/,q 53l90%
ARCHJTECTIENGINEERNAME LICENSENUM1IOER •7 (J7 BUS.LIIC.rA U '1 1
COMPANY NAME EMAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Mulb-Famrly, ROOF AREA'. V,CLUATION'.
STRUCTURE ❑ Convnercial [pa`1 S 1
EXISTING ROOF TYPE: 1:1RI11LT-UP ROOF 11 ASPHALT SHINGLES JaWOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOTE(REPLACE YES IFNO. PLYWOOD 1S' ❑ PLYWD ❑ OSB PITCH: ROOF
❑ NO r LAYER 1 K ❑ tB" TYPE ❑f 2 LA A
PROPOSED ROOF TYPE. ❑BUILT-UP ROOF L7 ASPHALT SHMGLES ❑WOOD SHAKES 13 WOOD SHMGLES ❑OTHER ICC-ES REPORT d
DESCRIPTION OF WORK. 1
O L"_3 Sl/N.j'Y-C. 1nLJ/ VTt.� Ji/L.V lG
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By my signature below,1 certify to each of the following: I=the property owner or authonud agent to act on the property owner's behalf I have read this
application and the information 1 have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
urdinances and state laws relating w building construction. 1 thona representatives of Cupertino to enter the—a7boveiidentified property'for inspection purposes.
Signatureof Applicant/AgenC Date: [ —9 —lZ—
SUPPLEMENTAL INFORMATION UIRED OFWCE USE ONLY
_ If building is associated with a Home Ownees Association,provide letter PWN CHECK TYPE ROUTING SLIP
of approval from HOA. VER-THE-COUNTER ❑ BUILDING PLAN REVIEW
Provide Planning approval to verify if there any resvictions. ❑ EXPRESS ❑ PLANNING,PLAN REVIEW
_Provide copy of Malmfacturer's Installation Specifications. ❑ STANDARD ❑ FIREDEPT
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OMER:
Reroofdpp_2011.doc revised 03.16/11