05020144 a CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORTNPORMATIOI�
auILDINO ADDRESS: MILDRED LEACH PBaMrr N'65020144
R A ENBBRGAST AVE PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
I
CHIIECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
1 lemby amen that 1 am licensed under provisions of Chapter 9(rommeMln{ P
h Section 701q)of Division 3 of the Business 4W Professions Code.and my licensee
ull fora a d ef(aL
z Lt...Class Lk.N REROOF
D.m cumnc
ARCHITECTSCon DECLARATION
I understand my Plans shall be used as public records
o Licensed Professional
OWNER-BUILDER DECLARATION
+� f I hereby alum on I am uusin s anrom the ession h Any c Law for the
p O following moon.Permit
t 7(D IJ,Guiness and Improve,
dWuns Code:Any city or county
$ which requites a permit re cnnswe,alter,nt fmw,h Permit t or repair ed structure
prior miucensed c,also
uanttohrequires lMvisio of for sucft Comment's
omm ntuofileux,Law stateroom
Fso that heincingwdpuection7 )ofDislonsnofftBtsinessandPraclaw(C6apmr9 Sq.FL Floor Area Valuation
that
with Section 700 d the
Divisorsr of NC Business and on.My vi Code),an of
Net h u eumPt them(rom retl Ne bait fa Ue alleged exemption.MY violWon of
Section 7031.5 by any applicant far a permit subjects the applkmt to a civil penalty of 3 WFJ43I'�3e1O 0 Occupancy Type
not mote dun five hundred dollam($5007.
I,u vwnnr of the propwy.w my employees with"M u tieu ole cmnpewdon,
will do the work.and the sounure Isnot lateral or offered forsak(Sa.70M.Buurcss Required Inspections
real Profealens cede:Ten umm
Comr'a License law de eact appy m 4n owner or 9 P
property who builds or improves themomand whodoessah work him cifmthrough his
awn employers,pmvided Nal such tmprowmenu ase notineMW sea@need fouler IL `////\�
builder Neaveteorimprowmann Tidalwithinnueyear or improve
for throw of
builder MR have de burden of proving Nn he tlltl not build a improve for purpose of
oak,).
❑1,as owner of ct proper(,,Business uclus and contracting with;)Theed cenammn . F /�
cam,La d project(Sewn an weerofand ny who
Code;)Theves daemon.
and
came[caw doer not e te owner of proper(who builds or improves Nercon.and �w
who c U.,for such pmjecu with acantracroNU licensed pursuanlrothe ConmcmM1
Liaise law,
❑'la..m+ax'e6. .. ,B&PC(a Nis
nu!)Gi Ca De¢�
KER'SCOMPENther a DECLA0.AT10
1 hereby a1Nm under penalty of perjury oro of de following declarations:
1 have and will mainuln a CeNOcam of Consent to self-same,for Wmku'aCmarsm-
1M31M
tion,u.(ft provided for by section 37M of the Labor Code,fa the per(ormanee of Ne
rk for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurance,ss required by Section
e( Labor Cede,fa the performance of de work far which Nu sued
Permit Is is .
y Worme.Compensation buunnce amu and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu aa0on need not W completed Ude Permit is Tama hundseddu0an($100)
or leu.)
1 ardfy that in to perfoemmee of the work for which this permit is issued,I Nall nm
employ any peace in any man m become subject to the Workers'Compensation
Laws of calif
Applicoo L!
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should
become subject to Ne Worker's Compensation provisions of the labor Code,you must
.,O forthwith comply with such provisions or this permit shall be lamed revoked.
y CONSTRUCTION LENDING AGENCY
1Mrcbya(firm Nat Nem Its coutructinn lenNngageay for the Performance of
lYi> the work fur which this Permit Is issued(Ser.3097,Civ,C.)
0Lender's Name
L.
Z)Z building Address
V Q 1 certify Nu 1 haw mad!this application and sam that the above in(am W un is
F correct.l agra to comply with all city and county aNinames and state laws misting to
Q U building ndoned ro mtl hereby forhumuNorimmosses. taws of Nu city reenter upon the
L1J above-mentioned progeny for W pity an lamp ha
gy elder)agma ro taw,indemnify and kap harmless de City of Cupertino against
h ince sequin a of tocoming expeua which may I.any way acus against aid City
t.)7 A PLICA T of Ne granting of Nu Permit
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REG
z Re-roofs
Signaturto Appli UConummr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building=opal[rote or handle hanNaus mammal
as defined by Ik Cupenlno Municipal Code.Chapter 9.11,and the Health and Safety
Code.Salon 35533(x)? All roofs shall be inspected prior to any roofing material being installed.
0 Yea
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hmardnu air coome inane u donned by the Bay Area Air Quality Management all new materials for inspection.
isvicl7
❑Yes Iff1
I have mW the husstlnus materials mqueomentsundcr Chapkr6.95 of the Califor.
nia Health&Safaty Cade,Satiou 25575,35533 aW 25534.1 undemund Thu lfthe building
dens not currently have a tenant.Nm It is my mapomibilsty In madly the occupant of the
rcyuircmcm which µsigns rpffr i ane,aracertinaemofas y Signature of Applicant Date
Own orauthumcde cn am All roof coverings to be Class"B"Or better
Community Development
10300 Torre Avenue
� Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #o.S-dZ 6/Z/
�E '��/ j
OWNER'S NAME: - PHONE O$ /655
GENERAL CONTRACTOR �j FAX #
I am not using any subcontr rs: gym" / r�
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408) 777-3228
UPEI�TINO 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.
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 1/4" 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
dppolicy
/onn re-roofing.
Homeowner's Name: //om; 4 D/2CtJ
Job Site Address: /BCJ `t ��E/V�EdZ�f�S� Ace-5
Roofing Company Name:
Applicant's Signaturex. #hJAJ- L "Z Date: —/V/0-5
l V/0,j
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
• A. ✓ All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
be performed
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
_performed
............................................................................................................................................:........................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signature:.0 lwze,& Date: S�
job Address: 1861// PENb1-24AV- .90df Permit#
Any changes to the information provided on this form shall be submitted to the City of Cuyertino Build
• Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C U P S kT I A 1 O Phone: (408)777-3228
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors,then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation•
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until theverification.is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO
a REROOF
CUPER INO PERMIT APPLICATION FORM
APN # Date:
Building Address:
-
Owner's Name: Phone#:
2 -xJe o 5 7 (5
Contractor: Phone#: License #:
Cont 0 P ne#: Cupertino Business License#:
e25
e of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof -
X Asphalt Shingles A 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:
T 2 E aP_ LAY L 9 ►�
Residential A Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D
there are any restrictions: Eept. if
Cost of Project:' 00000 Type of Construction: Occupancy group:
Qty. if
Applicable 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
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