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13070128 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10479 HENEY CREEK PL CONTRACTOR:SHELTON ROOFING PERMIT NO:13070128 OWNER'S NAME: DINJ 1988 LEGHORN ST DATE ISSUED:07/22/2013 OWNER'S PHONE: 6509030309 f txe-oil MOUNTAIN VIEW,CA 94043 PHONE NO:(650)961-7699 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALU License Class C',7 � Lic.# '12— oq RE-ROOF 45 SQ-TEAR OFF SHAKE ROOF,INSTALL 1/2" S � 'l�� 2z — CDX PLYWOOD INSTALL NEW COMP ROOF CLASS A Contractor °teL Date I hereby affirm that I 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: 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. Sq.Ft Floor Area: Valuation:$23786 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:34248013.00 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 1 0 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 rD M 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 the !3 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non- oint source regulations per the Cupertino'Municipal Code,Section 9.18. RE-ROOFS: Signature7z " Date Z ( All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. r�/�/�//�� ❑ OWNER-BUILDER DECLARATION Signature of Applicj� h�"litlA�y Date: 7 ZZ an I 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 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. I 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(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 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 Air Quality Management District I performance of the work for which this 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 Health&Safety Code,Scctins 25505,25/55 3,and 25�534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent "l �'�d2 7 Date: 22 r 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 APPLICAJ 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 accrue 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 re CITY OF CUPERTINO REROOF `I" 6CUPEkT1N0 PERMIT APPLICATION APN # Date: 013 //2 13 Building Address: IV Owner's Name: V_�, oPhone#: HOA: Yes �-3 ❑ No If es provide letter from HOA Contractor: � �. �-, Phone#: 4�000^ q_z� Fax#: &5lb--f 6 Cupertino Business License#: Contractor License #: — Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles ,_ Asphalt Shingles Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) Number of existing coverings l ❑ Provide I.C.C.E.S. Report# ❑ To be Removed ❑ Provide Mfgr. Installation Specs. Job Description: 7� G , ',T4 Kip e—P K P hz o rnK. 9j Uhf SI O Residential Commercial ❑ Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if Green Building Checklist & attach it to the application or if there are any restrictions: ❑ applicable, include in plan set & the sheet index. Valuation l I Hav Read, Understand and Will Comply with Cupertino's Tear-Off Policy: Sigfiatdre Revised 02/05/09 CITY OF CUPERTINO REROOF CITY OF CUPERTINO FEE SCHEDULE Number of Fee ID Fee Description Fee Permit.Type Squares Group ' 1REROOFCOM Re-roof Cbmmercial B 1COMMLROOF 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICO Seismic Commercial B 5 1RER00FRES Re-roof Residential B 1SFDWLR00F 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 REROOFMRES Re-roof Multi-Family B 1MFDWLROOF 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1BUSLIC. Business License B CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10479 heney creek pl DATE: 07/22/2013 REVIEWED BY: Mendez APN: I BP#: "VALUATION: $23,786 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Du lex PENTAMATION 1SFDWLR00F USE: P PERMIT TYPE: i WORK RE-ROOF 45 SQ-TEAR OFF SHAKE ROOF INSTALL 1/2" CDX PLYWOOD INSTALL NEW COMP SCOPE ROOF CLASS A FEE ID ROOF AREA s.f. 1REROOFFRES 4,500 a- :Meeh. Plan Check Phamb. Plan Check F_lec.Plan(."heck �Iech. Permit Plumb.Permit Fee: Elec. Permit tee: other;Wvch.Insp. 0dier Plumb Insp, Olirer Elec.Insp. ID 11ech. Insp. Fee: Plumb. Insp.T ee: Etc hasp, Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,eta). Theseees are based on the relimina information available and are on[ an estimate Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee Plum h.1Mech.,,Flee Permit Fee: $720.00 Suppl. Ins°p Fee Plumb./llfech./Flee, Plum.h,/_,-111eeh.1Elee PermitT'ee: Consi action Tax: Administrative Fee: Work Without Permit? ® Yes (j) No $0.00 Advanced Planning Fee,,;.- Travel Documentation ees:Travel.Doc:umentation Fees: � Strong:Motion Fee: IBSEISMICR $2.38 Select an Administrative Item.' Bldp,Stds Commission Fee: 1BCBSC $1.00 ��0 ��I- wis $723.38 $0.00 �rQ, T EES $723.38 Revised: 07/01/2013 ti Community Development Department Building Division City of Cupertino 10300 Torre Avenue Telephone: (408)777-3228 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 2007 IBC Standards and manufacturers specifications on re-roofing.All roofs are Class "A"per Cupertino municipal code 16.04.080. 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. 7. NOTE: If you call for,a,plywood nail inspection and the job is not ready, you will be charged.a re-inspection fee of$176.18. The re-inspection fee must be paid before another inspection can be scheduled. IMPORTANT: 1. Flat roofs must have a minimum of V4"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: Job Site Address: K Roofing Company Name: &tte- Applicant's Signature: Date: ( ( Greg Casteel , Building Official Revised.,07/30/08 283588 aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM@D/YYYY) 5/2/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Construction&Real Estate Practice PHONE FAX (866)358-1487 AIC No Wells Fargo Insurance Services USA,.Inc.-CA Lic#:OD08408 EMAIL : CertRequests@welisfargo.com 959 Skyway Rd.,2nd FI INSURERS AFFORDING COVERAGE NAIC# San Carlos,CA 94070 INSURER A: Navigators Specialty Insurance Company 36056 INSURED INSURER B: General Insurance Company of America 24732 Shelton Roofing Co Inc. INSURERC: Cypress Insurance Company 10855 1988 Leghorn Street,Suite C INSURER 0: INSURER E: Mountain View CA 94043 INSURER F. COVERAGES - CERTIFICATE NUMBER: 6010392 REVISION NUMBER: See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE OL SUBR POLICYNUMBER PMNWD EFF MOOLIC EXP LIMBS LT A GENERAL LIABILITY SFIICGL01740902 5/1/2013 5/1/2014 DAMAGE ToRENTED EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES E.occurrence $ 700,000 CLAIMS-MADE FRI OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JO- LOC g B AUTOMOBILE LIABILITY 24CC30126220 5/1/2013 5/1/2014 COM ED rt)SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Peraccldent $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADS AGGREGATE $ DED I I RETENTION S $ WORKERS COMPENSATION X7 ICY U IU- OTH- C AND EMPLOYERS'LIABILITY YIN 03300055805121 10/1/2012 1011/2013ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ NIA _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 if yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION EVIDENCE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)