06120062 CITY OF CUPERTINO ^amu > 7_,L- ''"
BUILDINb DIVISION PERMITxCON TRACTOR INF�ORM�ATION »
BUILDING ADDRESS: SMS ROOFING PERMIT NO. 06120062
OW NER'S NAME: PERMIT ISSUE DATE
TWOMBLY HURD W AND NELLIE V 1900 DOBBIN
NE: SANITARY NO. CONTROL No.
(408)254-7904
ARCHRECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p� LICENSED CONTRACTOR'S DECLARATION Job Description
FF I hereby affirm that 1 sm Renamed umkr Provisions,of Chapter 9(commencing
i.Ztd with Section 7")of Division 3 of the Business and Professions Code.and my licenm is
'tea in full forte anderm, REROOF- TEAR OFF EXISTING, SHAKE COMPOSITION RO
ss
i = Lieeone aLie.g
�_[+7
Dam Co. REPLACE WITH GERARD STEEL TILE
DEC
pp RCHITECTS DECLARATION
i C a I understand my plain shall W used as public records -
ayU
o t, Licensed Pnafessianal
OWNER-BUILDER DECLARATION
S 1 Wrchy,aRrm that I em exempt from IW Contractors License Law for Ne
no following mason.(Socum;]0313.Business and Pmfcssinns Cade:My city or aunty
!2r$r which requires a Permit in construct alder,impmva,demolish,or.,.it any structure
-I01 prior to its issuance.also mquims to applicant for such permit to rile a signed statement
Nat he is licensed purmanttoOe provisions of the Conwcwr's license Law(Chip.,9 Sq. Ft. Floor Area Valua$015950
(commencing with Section 7000)of Division 3 of the Business and Professions Coda or
that he u eumfe drrefsom and the basis for the alleged eaempuon.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mart dun ftas hundred dollars(55(10). 32619090 . 00
I,ss Owmrofoepmpcny,ormyemPloymwiN"g mtheumlee=N=don,
will do the wart and thessructurt Is not Watched car arfmred for sale(Sec.7(146,Business
and Pmfesdam Coda:The Canuacke,Liar¢law dart mupply Win Owner of Required Inspections
pmPeny who Mui Ids or impmw thereon.and who dos such work himself or through his
awnemployems,provided Nat such impmsemou art cot inteMN oroacmd forsa e-IL
however,the Wilding or improvement u mid within one year of mompleucn,the owner-
builder will love the burden of proving Nat he did Out dub Or improve for puryose of
sat.).
17 1,as Owner of the property,am exclusively contracting with Iicamsed contractors w
construct We project(Sec.]Obs.Business and Profadoes Code:)Tie Contractors U.
cense law does not apply to an owner of propeny who Wilds Or impmw themon,and
who contracts for such projects with a eontrumKs)licensed pwaun,to the Cantranwrs
License Law.
Fl I am exempt under Sec .B&P C for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of parjury,one of the following declamtlans:
1 ham and will maintain a Cerufnam of Consent to self-insure for Warkds Compcn-
satiun,as provided for by Section 37M of tie labor Code.for the Performance of the
work for which this permit'u issued.
k1 have and will maintain Woraces Compe aidlon Insurance,o required by Section
7 of Ma labor Code,for de performance Of the work for which this permit it issued. '
MY Workers Compensation Inorganicorties and Policy nugqmbm
h�er a :
Cartier. -,STr Policy No.:&25S 06
CERTIFICATE OF EN&PTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section teed mm W camPkud if Ne Permit is fixture hundred dollar($100)
Or less.)
I codify that in Ne performame of Ne wort for which this Permit is intend.I shall not
employ amypermn in any manrcrsn as to become subject he the Wmken'CmnpcMaM.
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:If.afar making Nu Continue of Exemption.you should
became subject to thin workers Comp=dm previsions of the labor Cade.you most
,J O foMwith comply with such provisions or Nis permit"I he docmad cvokcd.
z ` CONSTRUCTION LENDING AGENCY
[—ice I hereby all ter Nem is a construction lending agency for the performance of
Me work for which dtis permit is lntued(Sec.309],Civ.C)
0,Q 4ndcrs Name
z lenders Address
U 0 1 cenify that 1 have mad Nis application and stow Nat Ne above information is
U.P correct.I agree to comply with all city and county oNiwnxs and stats laws relating in
DU Wilding construction,and hereby amhorze mpeesenuuves or his city in enter upon the
Ld1 aaovc-mcntiunedpmpcdy for dipmend.seems andmitpedon roirpowhich m.
F G (We)agree to saw.Indemnify and keep harmless Ne City Of Cupertino agemn
UN fincoidesumuccoibegram"'Wopertw which may In anyway accrue against said City
O z A conseq prT of the granting iSN permit. I I
^ APPLICANT UN STA AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU IONS
Re-roofs
Signazure Applic ZA4` on r w'
A; US MATERIALS DISCLOSURE Type of Roof
Will de applicant or future Wilding occupant a.or handle h cendous mawrul
na defined by the Cullom Municipal Code.Chapu,SAL and the Heald and!Safety
Cale.Section 35532(x)]
Cl Yea 0 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding eceupan,ave equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air comaminants as defined by Ne Bay Area Air Quality Mamgmerms all new materials for inspection.
Dimict7 ffua-l� _
❑Yes PON.
1 hove real Me avarG''us'mamriaunequicmenu under Clupmr G95of de Cilifor.
ria Reed"Ssl)yCode,is, it is M 33 and25534.I to orsund a occum Wilding
does oat cur 1 v:;ton t It u my pondhility to maty do ocapant of Nc
requinerm, mbe c 'arm' roar aCahrieateofOccupancy. Signature of-KIpplicanif Date —
Owner&,athnded ant Dow— All roof coverings to be Class"B"or better
r - Community Development
e 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
*UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
fZ41RdNb Ulr w LAI -
OVVNER'SNAAo[E: JOE I PHONE # & 7 Cj/ 7e
GENERAL CONTRACTOR C L- FAX #
I am not using any subcontractors: Z /
Sign Cure 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
CITY OF CUPERTINO
sem 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32619090 . 00
DATE ISSUED. . . . . . . : 12/14/2006
RECEIPT # . . . . . . . . . 37050
REFERENCE ID # . . . : 06120062
SITE ADDRESS . . . . . : 21917 GARDENVIEW LA
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TWOMBLY HURD W AND NELLIE Y
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1131
RECEIVED FROM . . . . : MEL STEPHENS
CONTRACTOR . . . . . . . : GRAEME BLACKBURN LIC # 27125
COMPANY . . . . . . . . . . : SMS ROOFING
ADDRESS . . . . . . . . . . : 1900 DOBBIN DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408) 254-7904
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- ------- - - ----------- -------- -- ---- ----`- ---------- ---------- ----------
BPERMFEE VALUATION 16, 000 . 00 234 . 36 0 . 00 234 . 36 0 . 00
BSEISMICRE VALUATION 16, 000 . 00 1 . 60 0 . 00 1 . 60 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 235 . 96 0 . 00 235 . 96 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 235 . 96 1001
TOTAL RECEIPT 235 . 96
•
1' 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 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 policy on re-roofing.
Homeowner's Name: RI T a [_C
Job Site Address: Z 19 t 7 Qi P&M-by l W LA!, CctPCRTi OU Z>,
Roofing Company Name: 5 C-Iq L - P!}C.
Applicant's Signature: 7 Date:
• Greg Casteel
Building Official
Revised 11/2/04
CITY OF CUPERTINO
S REROOF
CUPERTINO PERMIT APPLICATION FORM
APN
Bul rng Address: 1
Owner's Name: Phone#:
LEE-. 41s
Contractor License#:
s Ms a S_S 347 ,
Contact: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
_ Asphalt Shingles ❑ Asphalt Shingles
!kC! Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify) Gf1(
FRz TILE,
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: p
P E _ E 5 [ — ooFg I EPu4- W E STEEL T�
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of roject: 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
•