13020063 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 862 LILY AVE CONTRACTOR-7t/hS PERMIT NO:13020063
OWNER'S NAME: LESTER CHEN DATE ISSUED:02/122013
OWNER'S PHONE: 4083683350 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
17
License Class L —37 Lic.H Z014904'D TEAR OFF(E)WOOD SHAKE&INSTALL NEW CLASS A
Tlr s Cr,106 D�L Date '9' �� COMP
Contractor ROOF SYSTEM 3T S,?
I 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.
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as providedfor by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$11000
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:35903037.00 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 W9JRK4S NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 D P T 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 OM L 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 the 2i Z
granting of this permit. Additionall the applicant understands and will comply I y: Date•
with all non-point source mgula' per.the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaini7in, n,I agree to remove all new materials for
inspection.
13 - OWNER-BUILDER DECLARATION
I hereby affirm that am exempt from the Contractor's License Lew for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"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(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 Bay Area M Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cuperti nicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2559(3$533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dat1 �
permit is issued.
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 _
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 862 LILY AVE DATE: 02/12/2013 REVIEWED BY: MELISSA
APN: 359 03 037 BP#: "VALUATION: $11,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY NTAMATIOSFD Or Duplex PERMIT TYPE:USE: 1 SFDWLROOF
WORK TEAR OFF E WOOD SHAKE INSTALL NEW CLASS A COMP
SCOPE
Meeh. Pkm.(' Plumb.Phin Cheek Glen.PLrr.Ched,
Gtech.1'..•rmit Pee:, - Phmtb.Permit 1,ee: F1ec. Pel mii 1,ez:
Other ddech. hup, Other/'lump fns/;. Olher E1cc.Imp.
;bleach.1,1q,F,.,e: - Plumb./nsp.Fee: Ekac. hrsP.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on thereQmina information available and are only an estimate Contact the Dept for addu7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 3,400 s.f. Re roof
Suppl. PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 $510.00 1REROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. ®OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C'nnsiraction Tac:
Admirrisiralive Fee: 0
Work Without Permit? ®Yes iq No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
lTrzeell�ncumsitta/itinFter: Building or Structure
Strom Motion Fee: iBSE1SMICR $1.10 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$2.10 $510.00 mTOTAL�FEE''` $512.10
evised: 01/01/2013
REROOF PERMIT APPLICATION (�b
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ) O
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 h, I/
CUPERTINO (408)777-3228•FAX(408)777-3333•building0cuoertino.oro M
PROJECT ADDRESS g7Z
�/J Jr/i/ ��. /A �p ♦APN p �f 7 /�,
OWNERNANfE � r„'I� (J(! PHON
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1J 2S D lMA/n. J
STREET ADDRESS y�2 / )/�OCITY. STATE,ZIP /u7/y�,y–/ter urf FAX
CONTACT NAME ` I PHONE
STREET ADDRESS CITY.STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENI ❑ CONTRACTOR ❑CONIRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAME wiG1�I LICENSE NU% L!V LICENSE
TYPE BUS.LIC.M/ �L,-
COMPANYNAI� VP� 'E'S
STREET ADDRESS /�,A//lt/ �✓. 9V Z_ CITY,STATE,ZIP 6� PHONE bd V'�WP 0'9&7
ARCHITECTIENGINEER N AME (•/lfl� LICENSENUNSER '\/(• C/R1 BUS.LIC.9
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex Multi-FamilyR�O/OF AREA: VALUATION:
STRUCTURE: [3 Commercial SI e ly a� " ACS"�I ftN 7
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES XWOOD SHAKES ❑WOOD S(HINGLES ❑OTHER(SPECIFY)
REMOVE)REPLACE ❑YES
IF NO, PLYWOOD 'h" ❑ PLYWD zy OSB PITCH: ROOF
❑ N # R Tm ❑ 5B" ❑ D —'12 CLAS `�
PROPOSED ROOF TYPE: ❑BUILT-UPROOF ASPHALTSHINGLES ❑WOODSHAKES ❑WOOD SHINGLES 11 OTHER ICC-ES REPORT#
DESCRIPTIONOF WORK: _ n 9'..I _� e,_JNLS/Q-
N �'
GV �///lIJ L4f
By my signature below,I certify to each of the following: ![,Ze roperty owner or authorized agent to act on[he properly owner's behalf I have read this
application and the information I have provided is correct. d a Description of Work and verify it is accurate. agree to comply with all applicable local
ordinances and state laws relating to building cxnsrructio . representatives of Cupertino to enter the above-i ntified properly for inspection purposes.
Signature ofAppticanUAgent Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
_If building is associated with a Home Owners Association,provide letter PLAN CHECK TYPE ROUTING SLIP
of approval from HOA. OVER-THE-COUNTER �'BUILDING PLAN REVIEW
_Provide Planning approval to verify if there any restrictions. ❑ EXPRESS //❑ PLANNING PLAN REVIEW
_Provide copy of Manufacturer's Installation Specifications. ❑.STANDARD ❑ FIRE DEPT.
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER.
ReroojApp_2011.doe revised 03/16/11
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: lZ y3 . PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR:, � 4d. P"V • BUSINESS LICENSE# �9
ADDRESS: CITY/ZIPCODE:
*Our municipal code requiresall'businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: A /3
re Date
Please check applicable subcontractors and complete the following information:
j/ SUBCONTRACTOR'S 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
1 /
Owner on' actor Signature ate