04050099 CITY OF CUPERTINO
BUILDING DIVISION PERMIT gONTRACTORdINFORMATION ,
BUILDING ADDRESS: PERMIT NO.,4'0 5 0 0 9 9
•OWNER'S NAME: PERMIT k55UE DATE
GARY HENRY 0511-2z2oo4
ONE: SANITARY NO. CONTROL NO,
ARCHITECIyENG1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a�ioo LICENSED CONTRACTOR'S DECLARATION
in
w 1 hereby affirm that 1 am licenacd n r provisions of Chopmr 9(commencing Job Description
Z� with csion]OfB)af Division3of NCB and!Pro(cssiun Cock.and myliccvcis
mu rad r 6 REROOF
La ata Lk.N
Zi., Dam camncm - - CONTRACTOR: CERTIFEID ROOFING CO.
ARCHITECTS D
10 jam}
1 undersunJ my plans shall k used as public recoNs
OnU
c G Licensed Professional
5 OWNER-BUILDER DECLARATION
in
Z1 herchy alRm Nm
ral I aexempt from the Cnnuaaor's License Law for ton
n D following reason.(Section 7011.5,Business and Pfufessions Code:Any city or county
yQ. u which mquioa Permit to construct.alcor,improw,demolish,at minor any structure
prior to its issuance,also require the applicant for such Permit o rile a signed statement
thathe alicentedPursuanua tkpmvisiousofthc Comracmri Li¢nsse law(Chapher9 Sq.Ft. Floor Area valu$t1(31000
a�sH$ (commencingwith Section 71100)orDivision 3ofthe Businessand Pronasion Code)ur
that he is exempt therefrom and Ne basis for one alleged exemption.Any violation of
Student 703 L5 by any applicant for a permit subjects the appllcmt to a civil penalty of APN Number Occupancy Type
not more Nen five hundred dollars($50().
❑I,as awneraf the property,or my cmploycewiN wagesulhcir sole compensation, 35716142 '_00
willdothework,Bndthcswcmrtisnotinuendedurofferedronam(Sec.]tkd.Business an$
and Pmfeaions Cc&:The Contractors License Law dos not apply m Required Ins recd an owner of q p 9 A n
property who builds or impram Nocton,and who does such work himselforNrough his
own cmployMs,provided Nnt such improwmanu art nmimende l car offered for sale,If.
however,the Wilding.,improvement mould withiniteycartifoormied...the owner- JUN 3 2004
builder will haw the burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑I.as owner of the,property am eseluavely contracting with licamed contraction to n n (\0 f4
G
construct the project(Sec.706,1,Business and Profusionsac
Code:)The Contrmri ®
Li- U &aIN
cause law does not apply to an owner of pmpcny who Wilds or immom thereon,and
wh comractefor such projects with a conuacmr(s)licensed pursuant the Contractor's
L' nm w.
exempt umler Sec. .B k P C for thin reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby alum under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for WorkctsGompen-
sation,as provided for by Stenon 3]00 of the Vbor Code.for the performance of tk
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
1700 of the labor Code,for the performance of he work for which this permit is issued.
My WmI ces Compensation Immou a carrier and Policy numko arc:
cr. Policy O.:
CERTIFIC OMPE EXEMPTION ORKERS'
COMPENSATION INSI ANCE
(lhu section octad not W completed if tk Permit is for ane hundred dollars,($100)
he less.)
1 cenify Not in Neperformance of the work for which this permit a issued.l shall not
emwsplay,of CCy,rOn.r y nc[.mssmheomc subje�t Wo ampersand..
Laalif man
kiplicam
NOTICE IL a maks g NE Certificate of Exemption,you should
biome subject in the ohe motion provisions of the Labor Code.you must
.J Z forthwith comply with such provisions or his permit shall he deemed revoked.
Z ';;3 CONSTRUCTION LENDING AGENCY
1 hereby affirm that Bert is a construction lending agency for the performmen of
tW work fur which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's N.
=Z Lender's Address
J O I Modify that I have read this application and sum that Nc above information IS
W F" corns I agree in comply with all city and county ordinances and sum laws relating to
0U building construction.and hereby authoma mpesenutim of Nis city in enter upon dm
>'W above-mentioned pmpeny for inspection purposes.
f'a (We)agree td save,indemnify and keep harmless the City of Cupertino against
rj) liabilities,judgmcnu.casts and eapense which may in any way accrue against mid City
U Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANM AN ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC G 0
Re-roofs
Sig 'Applic
AZARDOUS MATERIALS DISCLOSURE nuassorD Type of Roof
Will the applicant or future building occupant store or hastdle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode.S❑Yes uor25532(a)? All roofs shall be inspected prior to any roofing material being installed.
FS^T
LWill the applicant or future building Occupant use equipment or devim which If a roof is installed without first obtaining an inspection,I agree to remove
t hazardous air conmminanu in defined by the Bay Area Air Quality Mmagcmcm all new materials for inspection.
District? 11 1
❑Yes AN.
I have octad the harardousmsmrials requirements under Chapter 6.95 ofthe Califor-
nia Heath h Safety CMM.Sermons 25505.25511 and25536.I undcrsund thmif the Wilding
docs not en Ili ha ion tit a my respomihility m nedry the estop.,or Ne
requir nuwh m t sect brmixuanceOraCcrtificamo(Occupancy. nature fAppicant Date
All roof coverings to be Class "B"or better
net or m , gem m g
Community Development
i * 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB Ann : x/,'7 6 5Y vti e # 6'�USOU Cf cI
OWNER'S NAME je77.a!M PHO V -
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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 1
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing a y. n
Septic Tank
Sheet Metal
Sheet Rock
Tile
S�-(7 -e
'/contra/tor Signature ate
Community Development Department
j Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408) 777-3228
U P E IST I N O 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.
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 policy on re-roofing.
Homeowner's Name: �Gt V,44 e /l2 L,4
Job Site Address:
2 $7 6 .6y tie_ C *- -
Roofing Company Name: f ,, = i Cti
A p"cant's(Signature: Dat
Greg tee`
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF o o S' L> 71
CUPERTINO PERMIT APPLICATION FORM
APN # � � � ) /' � !�� Date: O
Building Address:
z 8 Z 3v v > e-
Owner's Name Phone#-
G't qyd
Co actor: hone#: License#:
�e,or6C; �
Co ct: Phone#: Cupertino Business License#:
avre,( e,,wgi° 129-5` 647-7g82—
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )< Asphalt Shingles
>W, Wood Shakes ❑ Wood Shakes
' Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings *WO ❑ Provide I.C.B.O. Report#
To be Removed 4 LN C? ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply Wth Cu ertino's Tear Off Policy:
Job Description ectv_ app 5 r N� �s Db S CSS �N
�(2 8S vt-, two a
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning t
there are an restric ' s:
Cost of Project: Type of Constructin: Occupancy grou .
LUZ
Qty. i
A lj a 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
2� � 3
CITY OF CUPERTINO
�m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 35716142 . 00
DATE ISSUED. . . . . . . : 05/17/2004
RECEIPT 4 . . . . . . . . . : 25560
REFERENCE ID # . . . : 04050099
SITE ADDRESS . . . . . : 21876 BYRNE CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GARY HENRY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1156
RECEIVED FROM . . . . : DAVID CAMERON
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
- -- - ------------- ---- ------ ---------- - - -- --- ---
BPERMFEE VALUATION 13 , 000 . 00 187 . 00 0 . 00 187 . 00 0 . 00
BSEISMICRE VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
- -------- - ---- -- --- - ---- ---
TOTAL PERMIT 288 . 30 0 . 00 288 . 30 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
--- - - - - - - - - - ----- ----------- - ----- ----------- - -
CASH 288 . 30
TOTAL RECEIPT 288 . 30