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0312001500 '3s A �z UO OH U Uz I CITY OR CUPERTINO ' CONTRACTQR INFORMATION BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NOO 3 12 0 0 15 lOS53 LA RODA DR :R'S NAME: PERMIT ISSUE DATE iKDISSY TOM S AND CAROL M 12/03/2003 ONE: SANITARY NO. CONTROL NO. ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MCCII 0 0 0 0 LICENSED CONTRACT'OR'S DECLARATION lob Description at I am licensed under provisions of Chapter 9 (commencing 1 hereby affirm Nns p With Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. REMOVE EXISTING SHAKE AND REPLACE WITH COMP SHI License Class Lic. N Date Commerce ARCHITECTS DECLARATION I understand my plans shall he used as public records - Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 on exempt from the Contractor's License Law for the following mason. (Section 7031.5, Business and Professions Code: Any city rte county which requifcs a permit to must ru.L, etre¢ improve, demolish, m mpzir-any souctum prior to its issuance, also requires the applicant for such permit to File a Signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Dominator's License Dow (Chapter 9 (commencing with Section TIDO) of Division 3 of the Business and Professions Code) or 'hat he u exempt therefrom and the basis for the alleged exemption. Any violation of 3 "10Qu-i>illier.0 0 - Occupancy Type Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of not more Nan live hundred dollars (S500). I, as owner of the pmporty, or my employers; with wages m their sole cmmpenss'ion. will do the work, and Ne structure is not intended or offered for sale (Sec.7 4 , Business Required Inspections and Professions Cult: The Cormamors License Law docs not apply to an Owner of property who builds orimptnvce themon, and whodoes such work himself orrhrough his own employees, provided that such improvements are not intended oroRerW for sale, If. however, the building or improvement is sold within one year of completion, the owner. builderwill have the burden of proving that he did not build or improve for puryo¢ of salede �'����® D 1, as owner of the property, am exclusively contracting with licensed conuacbm to construct the project (Sec. 9044, Business and Professions Code:) The Contractors Li. cense law does not apply to an owner or property who builds or improves themmn,and. ' APR r1 O 6 204 who can are Tease projects with a commmor(s) licensed pursuant the Convector's FS Licen wept I uncle ,B& PC far this .soon r BUILDING WORKERS COMPENSATIONRATION I hereby affirm under penalty of perjury one the fallowing declesetimm: D I have and will maintain a Certificate of Consent to self-asum for Worker's Camper- - sation, as provided for by Section 3700 of she Labor Code, for the performance of the .,it for which Nis permit is issued. ❑ I have and will maintain Worker's Compensation insurance, as required by Section 37W of the labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number art: Cartier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed Ethe permit is formic hundred dollars (SIC0 or less.) 1 certify that in the performanee of the work for which this Permit is issued. l shall not employ an aany manners. u to become subject to the Workers Compensation Laws al' n'�Dem i s eC ,Applies N ICE TD PP ICIANT. IL after making his Certify) of Exemplum, yeu should oma subject to the Worker's Compensation provisia2061 the Labor Cade, you mus' forthwith comply with such provisions or this Permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm our there is a ammo e,lon lending agency for the Performance of the work for which this permit is issued (Sm:. 3091. Civ. C.) Lender's Name Lender's Address 1 certify that I have read this application and sure that Ne be. information is Cormet. T agree to comply with all city and county Ordinances and some laws relating to building construction. and hereby amhorise representatives of Nis city to cnmr upon the above-mentioned Property far inspection purposes (We) agree to save, indemnity and keep barmlcss the City of Cupertino against liabilascri,ju ents. costs and expenses which may in any way acerae againmsaid City in career c of the gmnting of "I, permit. APPLI N UNDERST NO WI C MPLV WITH ALL NON -POINT Issued by: Date SOUR GULATIO r/, i., n -s Re -roofs - Type of Roof �(_ � VnihmirofAinplicautfiCondacibur Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building mapper, store or handle hararduus material &hard by the Cupertino Milgrairal Code. Chapter 9.12, and the Health and Safety e. Section 25532(a)? All roofs shall be inspected to any roofing material being installed. Yes prior .pmenr If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or fu building occupant use man or devices which m Omit ha solos all cr ommina dcfnmd by the Be, Arca Air Quality Management all rte materials for inspection. District? ❑Yes Nu 11 a ad the harardous materials requirements under Chapter 6.95 of the Caliror. niaHwl & afmyCodc,Seniorrs25505,25533ond255J4.IundcrsmndNatifthchuilJing 3 3 docs n t cu ally have a a t is ray msponsihili'y to nodl'y Ibe uecupeat of the .qui a as a. �t ,sin mcracmmct Oce aarmy. / Slgna[ureofApplican[ Date d All roof coverings to be Class "B" or better a� own o a, ONo'ivadngmm a&M, CITY OP CUPEkTINO 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. 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 coi Homeowner's Name: C Job Site Address.• Roofing Company Name: A phcant's Signature: 0 Greg teal Building Official with the above stated policy on re -roofing. Wo Revised 1/30/03 Printed on Recycled Paper Date: /r'3� 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 i 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. Owner -Builder Information (r se e). Property Owners Signa Job Address: �` � A)Q 04 w13 Devartment. I have read and understand the Date: Permit # Dear Property Owner: City of Cupertino Building DeF 10300 Tone Phone: (40 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 compensatiOle contributions. I i 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 the verification is returned. Very truly yours, Building Department, City of Cupertino Printed cn Recycled Paper 10 41 03i204i,5 CITY OF CUPERTINO 40 I REROOF CUPEkTINO PERMIT APPLICATION FORM APN # �� Date: Building Address r, ,6 6 oQ !� Owner's Name: (t//A ,/IHSS / �t Phone #: Seismic Fee Res BUILDING 35 73 Contractor: Phone #: License #: Contact: Phone #: Cupertino Business License #: Business License Type of Roof Covering: Existing: Proposed: ❑ Built -Up Roof ❑ Built -Up roof ❑ Asphalt Shingles E ly Asphalt Shingles `M Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other (Specify) ❑ Other (Specify) Number of existing coverings ❑ Provide I.C.B.O. Report # 9 To be Removed Cl Provide Mfgr. Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑ Job Description: \ �� " Residential .� Commercial ❑ Fire Zone: Yes ❑ No ❑ Confirmed with-Pliinin`g'Dept. if there re trictio s: ILLJJ Cost of Projec �,,,,,, ancy gr p: r Type of Cons Oc Y icab Annica Fee ID Fee Descrintinn Fee rlrnnn BPERMFEE Bldg Permit Fees BUILDING NERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING 117.60