06120036 CITY OF CUPERTINO
BUILDING DIVISION PERMIT =CONTK&4CTOR INFORMATION:l-
BUILDINCADDRFSS: WESTERN ROOFING SYSTEMS "'""N0'06120036
10197 AT)PTANA AVR OWNER'S NAME. PERMIT WITE DATE
� CAMPBELL GREGORY D 248. 7 AMARAL CT #C 12 /11 /2OQ6-
NE: SANITARY NO CONTROL NO.
(562) 426-7147
BUILDING PERMIT INFO
ARCHITECT/ENGINEEA. BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION Job Description
w I hereby affirm Nn I am licensed umber esc
der provisions of Chapter 9(commencing
;zn, wiN Section 7")of Division 3 of die Business and Profossiuns Cade.and my[jet.is
"es, in full forte and cff
�pz Lfull f Class n'i Lm.1 67�'��'Ir TEAR-OFF WOOD SHAKE & SHINGLE, INSTALL SHEETING
�Fp Dam contractor/ /L AS NEEDED, 40LES FELT, LIGHTWEIGHT METAL TILE 3
ARCHITECTS DECIIART91pN7-"
i < 1 understand my plans shall he mind u public records
)yU
w H Licensed Professional
s03
OWNER-BUILDER DECLARATION
Com ION
f I hereby a?nn 11. exempt from the Contnetars License
Any c Law for me
p o which a reuon. ormi(Section ca ear Business and Pmfecsmm Coda:Any city or..my rim,
which reymrra issuance.permit re cores t,alms.improve,h Perini u fie a sig any swctum
proor do mcd pursuant to din movisio csoffor Comoutteitm0les,Law(Utamen
5< (comma(commencing with 7000)orovrsions ofineicBuazmsandPreeLaw(Code)or Sq. Ft. Floor Area ValUr�5�19000
'52 that pt Section 8100)the Division of alleged casland Professions Code)or
� mat bo u exempt thctefmm and We buts for the alleged,•^ption Any violation of �
Section 7031.5 by any applicant for a pe,ma subjects the applicant to a civil penalty a' APN Number Occupancy Type
not mom than five hundred dollars(5500). 32620022 . 00
❑I,as owner of the property,Or my employees wrN wage as then In eumpwassaon,
Will do the work.and the sumom is nut imended or offered for wle(Sec.70",Random
and Professions Cade:The Conuxurs Lamas Law does nut apply in an owner of . Required Inspections
property who builesarmprow themvn,and whodoessuchwohhimselfor through his
own emplayc ia,provided that such Improvements arc not Intended oraRemd forsale.if,
however.me Wilding or improvement lt sold mohm arc yev of i ampletion,dw awrcr-
builder ,will have am burden of proving that he did ram Wild or improve for Purpose Of
sale.).
❑1.as owns of the propenY.am aelu evely coruw ini wads licensed commctuds no 1
construct the project(Sec.7W.Business and Professions Code:)The Conuances Li- -
cenw law doll not apply in an owner of property who Wilds or improves Merton,and �
who comets for such project with a can.,(Q licensed pursuant to am Cmdhwnors
Llecmm law.
❑I am exempt under See .B A P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 Mreby,affirm under penalty of pequry arc of the following declarations:
401 have and will maintain a Certificate of Consent o mlf-instate for Worlices Compen. _
ash.,as provided for by Section 37(st)of the Labor Code.for the performance of the
work for which mu permit is issued,
? have and will manmvn Worker's Compensation Insurance,as required by Scctjon .
t 700 of the labor Code,for the performance of the wort for which this permit is issued. ,
My Worker's Coma unnsation Insurance carrier and Policy number am:
Cartier. Sfa+*L �Wd` Polity NO.:�7a af1rJ^•O4-
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(Thus section reed not W completed if the Permit Is for orc hundred dollars(SIM)
or less.)
I ccrufv that In use Paf ormai of the work re,which this Permit is intend.I shall not
employ any Person in any mannerso as in became subject in ate Workers'Com,notauou
Laws of California.Dal-
Apponsnt _
NOTICE TO APPLICANT:IL armr making this Certificate or Exemption,you mould .
become subject in the Worker's Compcwtion provisions of the labor Cale.you mud -
.J z forthwith comply with such Provisions or the Permit shall x dccmrA muted.
ZO CONSTRUCTION LENDING AGENCY
[--r I hereby affrtn that there is a coravucdon lending sgene,for the perfammmx of
r1. the work for which this pcnnn rs..it(Sce.3091,Co,C.)
W~n- LeadcisNam-
7 z Lenders Adam— -- -- -
U C) 1 certify that 1 have read this application and state mat the above information is
ty carted I agree to comply with all city and county oNinances am sum laws actions to
0 V building construction.and hereby authorise mpresemaover of this city to enter upon the sy[ ,/1yp(/, /
r aWvesequeocdthe shyfar oft his Permit. .
cL (\�(�/�/�l
(We)agree w save,indemmfy and keep hamleas the City of C.,runo against
H N lmahuesjudgments.casts and expenses which may in any way secmc against sad City
(„)z mcanse ANT UNDERSTANDS permit. / 2
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date L
SOURCE REGUIATIONJ� 12 1)"e", _Q
) Re-roofs
Srgnazurt of ApPlicaNCantr pare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII cawapplicantwfutureijiil Cruamhaptuartahad healthadSeinl
C defined by the Cupertino Mummpal Code.Chapter 9.12,and the Hatm and safety
Code.orlon zss3z(an All roofs shall be inspected prior to any roofing material being installed.
Ya gNo
/ If a roof is installed without first obtaining n inspection,I agree to remove
Will the applicant a fuwm Wading occupant tare oywpmcm or dcviw which g P g
emit hazardous air contamwne,ai defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes N
I have real the hararal mamnais mgmremcna under Chapmr695 ofthe Gh(ory /
as Health&Safety Code,Sec ma 25505,25533 aW 25534.)understand thus dthc building
doll noycurrently bare a tenant Nat It a m msppmihilllY to rwufy the occupant of Ibo _
mouipCmcnu whteh muv be tact poor w' ofa[erufcate of Cksvpancy. GSIg tore Applica't Date
,11 ro coverings to be Class'B"or better
/)(vncr o ore cm \fir i nice-
CITY OF CUPERTINO
10em 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 1
Sec : Twp : Rng : Sub: Blk: Lot :
APN . . . . . . . . : 32620022 . 00
DATE ISSUED. . . . . . . : 12/11/2006
RECEIPT # . . . . . . . . . 37000
REFERENCE ID # . . . : 06120036
SITE ADDRESS . . . . . : 10197 ADRIANA AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER CAMPBELL GREGORY D
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : MICHAEL LUNNEBORG
CONTRACTOR . . . . . . . : MILLER, TROY LIC # 21457
COMPANY . . . . . . . . . . : WESTERN ROOFING SYSTEMS
ADDRESS . . . . . . . . . . : 2487 AMARAL CT #C
• CITY/STATE/ZIP . . . : HAYWARD, CA 94544
TELEPHONE . . . . . . . . : (562) 426-7147
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- - ----- - - - - --------- ---------- ---- -- - --- ---------- ---------- ----------
BPERMFEE VALUATION 17, 000 . 00 245 . 16 0 . 00 245 . 16 0 . 00
BSEISMICRE VALUATION 17, 000 . 00 1 . 70 0 . 00 1 . 70 0 . 00
---------- -------- -- ---------- ----------
TOTAL PERMIT 246 . 86 0 . 00 246 . 86 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- ---------------- ------------ ---- --------------
OTHER 246 . 86 VISA
TOTAL RECEIPT 246 . 86
•
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 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 vaid before another insvection 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 LC.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.
Homeowners Name: C;/t°! L''"��
Job Site Address: ���//�� '�7__c✓/iA/�Ny
Roofing Company Name: h7`f��✓lC dN/ S� q, /
Applicant's Signature Date:12-7e/-Ofo
i
• Greg Casteel
Building Official
Revised 11/2/04
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
6UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
loi5t- 4tj.- IqN4 I
OWNER'S NAME: I PHONE #
GENERALCONTRACrok- �sen�P�✓lvv�eGtj5v(� l I FAX #
J
I am not using any subcontractors:
Signatures Date
Please check applicable subcontractors and complete the�0wing information:
®
SUBCONTRACTORi BUSINESS NAME BUSINESS LICENSE #
Cabinets&Millwork
Cement Finishing
Electrical
( Excavation
Fencing I I,
Flooring: Carpeting
• I Linoleum/ Wood
Glass/ Glazing
Heating
( Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
J Paving
Plastering
Plumbing I I I
Roofing I I II
Septic Tank
Sheet Metal
Sheet Rock I I I
I Tile I I Il
Owner/Contractor Signature Date
CITY OF CUPERTINO
• i ��?'' REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# 2a(a, a�, Date:
Building Adddress:101y'7- l
Owner's Name: Phone#:
Contractor: / License#:
!vlr ,� "3 fy f/�i+✓all.�� .Y �6p li 7f 7 2 r—
Contact: Cupertino Business License #:
/jlrchae/LNir,�tb✓/z� !q7tpl w
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)A4-k/w/ -/,/Z-
Number of existing coverings Z Provide I.C.B.a. Report# tb D ro
_r To be Removed ❑ Provide Mfgr. Installation Specs.
• I I Have Read,Understand and Will Comply With Cupertino's Tear Off Policy: I
Job Description: J /f6tir fCf
5/ 1 Oe 4.420 J7 44e -e J'i n�'/0-. /W1/4/�alwl�l '61 NPi A.�, ,ko Ar I'e*,
Residential Comxrlercial ❑ 30`L�
Fire Zone: Yes El No Confirmed with Planning Dot. if JI
there are any restrictions: E J
Cost of Project Type of Construction: Occupancy group:
/7, odv
Qty. if
Applicablef Fee ID Fee Description Fee Group
I I BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING f
BSEISMICOM I Seismic Commercial BUILDING
BPLANCHK I Plan Check Fee BUILDING
BUSLIC Business License BUILDING
I I I I I
I I I I I
I I I I I