12090113 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20652GARDENSIDECIR CONT'RACT'OR:BRADSHAW ROOFING PERMITNO: 12090113
INC
OWNF,R'S NAME: LEE KENNETH AND MARGIE 1821 S BASCOM AVE PMB 160 DATE ISSUED:09/13ROI2
OWNER'S PRONE: 4083091256 CAMPBELL,CA 95008 PIIONF NO:(408)246-9930
LICENSED CONI'RACFOR'S DECLARATION .JOB DESCRIPTION: RESIDENTIAL, COMMERCIAL
LicenseClass__C—:5R Lie.4 -7 3 RE-ROOF 12 SQ-TEAR OFF EXISTING, INSTALL NEW
ConlmclorQ) YCF1fV Q-C Date 9113
ASPHALT SHINGLES CLASS
hereby affirm that 1 am licensed under the 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 penalty of perjuryone of the follmving 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 -
perfamhance of the work for which-this pennil is issued. Sq.Ft Floor Area: Valuation:$6000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance,of die work for which this APN Number:36232018.00 Occupancy Type:
permit is issued. - -
APPLICA\1'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 DAYSOM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of die q_Is12,
granting of this permit. Additionally,the applicant understands and will comply Issue) by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RF.-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material beiig installed.If a roof is
installed without first obtaining an ins cc'on,I agree to remove all new materials for
inspection.
❑ OWNER-RUILDER DECLARATION cuht: ry//3 /
Signature of AppliDate: -7
hereby affirm that 1 um exemp from the Contractor's License Lao for one of '
the following two reasons: ALI-ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole comfunsation,
will do the work,md.the structure is not intended or offered for sale(Sce.7044,
Business&Professions Code)
1,as owner of the property,am excluvvely contracting with licensed contractors to DA7.ARDOUS MATERIALS DISCLOSURE
construct the project(See.7044,Business&Professions Code). 1 have read the huzardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. T will
hereby affirm under penalty of perjury one of the following three o maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: health&Safety Code,Section 25532(x)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 Ray Area Air Quality Management District
perfomhance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Co ,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code.Sections 25.%%A5533 J 255
Section 3700 of the Labor Code,for the performance of the work for mhich this
Owner or authorize)agent: Date:
permit is issued -
I certify that in the performance of the work for which this permit is issued I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONS'IRUC1'ION LENDING AGENCY
become subject to the Worker's Compensuion 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
APPLIC NI'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 Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon the ubove mentioned property for inspection purposes.(We)agree to save
indemnify and keep lmrtmless the City of Cupertino against liabilities,judgments, ARCUITECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of die 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
t Revised: 07/01/2012
REROOF PERMIT APPLICATION RIV CO(v1t�7UNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 n
CUPERTlNO (408)777-3228 •FAX(408)777-3333'buikiinoacuDertino.Ora n O 1
PROJECT ADDRESSX)CC (� nS 1U C w APN
OWNERNMfE Awe PH L E-h1A1L
STREET.ADDRESS :. STATE,ZIP CE} FAX
Co
CONTACT NMIE PHONE EALAIL
STREET ADDRESS CITY.STATE.ZIP FAX
❑OWNER ❑ MYNEA-BUILDER ❑ OWNER.AGENT MICONMIcroa ❑CONTRACrORAGENT ❑ ARCHITECT ❑ENGrKER ❑ DE`/ELOPER ❑TENANT
CONTRACT RNAA� LICENSENWfBER LICENSETYPE BUS.LIC.e JL
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COMPANY NAME ESU FAX q)2 _
STREET.ADDRESS G(TY.STATE IP PHONE
Ter Cat: 4
ARCHITECT,ENGINEER NAME LICENSE NM(BER BUS.UC.s
COMPAM'N.At E-MAIL F.A.[
STREET.ADDRESS CITY.STATE ZIP e-� PHONE
USE OF ❑ SFD or Duplex ❑ Pluld-Familq ROOF AREA: t /^�/ r VALU.AtJ(yJ:
STRUCTURE. ❑ Commercial V� (!jiytL
EXISTINGROOFTYPE: ❑BUILT.UPROOF ❑.ASPHALTSHD:GLES WODD sHAKES ❑t OODSNINGLFS ❑OTHER(SPECIFY,
REh10VE,iEPLACE 94ES I [F NO, /11 PLY.VOOD 15" ❑ PLYAVD ❑OSB PITCH: .(2 ROOF
❑ 0 S y THICKNESS ❑ i�S ❑ f0
PROPOSED ROOF TYPE: ❑BUILTAP roOF 2 ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER [CC-ES REPORT a
DESCRIPTWN OF NORK: � .�
By my sig nature below.I certify m each of the folio%ine: I am the property owner or authorized agent to act on the property owner's behalf. l have read this
application and the information I have provided is con ect. I have read the Description of YVork and verify it is Bceumte. I agree to comply With all applicable 1=1
ordinances and state laws relating to builllin con�/7-+�q�on. I a�u/dpn/zy�apresentatives of Cupertino ro enter Ile—abbove-idendfy!d property for inspection purpou.
Slgttatureol'Applicant/Agent: t,fM�.�./___yl-C'-�L� Date:
SUPPLEYMNITAL INFORMATION REQUIRED OFFICE USE ONLY
_If building is associated with a Home Owners Association,provide letter P�LANCHECKTIPE .� ROUTING SLIP
ofapproval from HOA. (A-'OVER-THE-COUNTER BOaomG PLAN RE VT"'
Provide Planning approval w verity if there any restrictions. - ❑ EXPRESS ❑ PUNNING PLAN REVIEW
Provi ac
Opypy of Manufacturers Installation Specifications. ❑ STANDARD ❑ F[REDEPr
,ovule signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
RerDofdpp_2011.doc rvvised 03.7(4.1/
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
172 ADDRESS.2_06�SI- gardenside circle DATE: 0911212012 REVIEWED BY: bobs.
,1PN: BP#: 'VALUATION: $6,000
*PERMITTYPE: Building Permit PLAN CIIECK T)'PE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1SFDWLROOF
USE: PERMIT TYPE:
WORK remove existing roof. Install new asphalt shingles 1200 s.f.
SCOPE
Meth. Ilan Check Plumb.Plan ChccA Flee. Platt Check
blech. Permit Fee: Plumb. Permit Fee: rlec. Permit Fee:
Other Meth. Insp. Other Plumb Insp. Other Elec.Insp.
,Meth. In.yi. Fee: Plumh. brat. Fee: Flce. hisp.Fec:
NOTE: This estimate does not ineludejeev clue to other Departments(i.e. Planning, Public 11'ark.s, Fire,Sanitary Server District,School
District,etc.). These eev are based on the preliminat3 information available and are only an estinmle. Contact the De t or addn'I info.
FEE ITEMS (Fee Resolution 11-053 F_/Z 71111_11 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 FEE] s.f. Re-roof
Suppl. PC Fee: Q Reg. Q OT p.0 hrs $0.00 $180.00 IRFROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee o Reg. Q OT F0,0 Fhrs $0.00
PMH Unit Fee: $0.00
PME Permit Fee: $0.00
Constriction Tax:
Adminicn•ntive Fee: O
Work Without Permit? O Yes Q No $0.00 E)
Advanced Planning Fce: $0.00 Select a Non-Residential 0
Travel Documentation Fu s: Building or Structure 0
Strong Motion Fee: IBSFIS,MICR $0.60 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.60 $180:001 TOTAL FEE: $181.60
Revised: 07/01/2012