04060218CITY OF CUPERTINO --
CCI,X12.-C�"I'Q.,ZNk'U{.h'IATION•
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NCO 406021
10255 MIRA VISTA AV
OWNER'S NAME:
PERMITISSUEDATE
DENNIS HOULSBY
06/25/2004
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BO ELECT PLUMB MECH
O
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
P
with Section7") fDivlidO 3 of the Buaineas and Profession. Code.andmylice.is
REROOF
In full fort, and effect.
License Clean Lic.Is
DateContractor
ARCHITECTS DECLARATION
1 undersand my plans shall he used as public records
Licensed Pmfcssienel
OWNER -BUILDER DECLARATION
1 hereby
sect on 1 em ,Burin from the Contractors License Law for the
.
folloj which un ones,.. (Sedan ]onstr, Business and Improve. demob Cade: Any city or county
eller, impmvq or sig any swmum
which requires a permit re cures
$2000
the h Permit t e a statement
priothat heslcensedpuru requires lhovisio s of forMe sucConncrnlll to ER`aal Law
that he incing
to the pmvivision
Sq. Ft. Floor Area
Valuation
with Sectio
of Busies'snicenmisons Code) or
(commencing with Section]gp)of DivisionJnf NC Business and Professions Cnde)or
that he is exempt thenfmm and the basis for Ne alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects Me applicant m a civil penalty of
A e
Occupancy Type
not mom con five hundred dollars ($SW).
❑ I, as owner ofthe property, or my employees with wages m their sole compensation,
will dothe work and Meatrucmm is not intendedoroffered fomtle(Sec.704a, Business
Required Inspections
and Prefessiona Code: The Contractor's License Law does not apply to in owner of
q p
propertywho bolIdsminqu vee Merton,andwho doesouch .,it himaelforthmugh his
lme im
psommwithinnns neyearoc moReeed for
oy .. pr vide Maisuch a
Own empver.
within one ownaL
however, theea,p building or improvement la field of Compl,ioa, oWMr-
y
builder will have Me burden of proving Mat be did not build or improve for purpose of
"I..).
ZJ
❑ 1. a5 owner of the property, am exclusively convecting with licensed contractors to
concoct Me project (Sec. 7044. Business and Prefeashms Cade:) The Camancmrs Li.
cause law does not apply to an owner of property who build, or improves Merron, and
/
who contracts for such pmjecle with a conosetor(0 licensed pursuant to Me Contractors
•V�(`Y_/7
earn Law
1 an exempt under See. B & P C far this rcacon
caner .1�
Oh TENSA' OECLARATI
1 hereby affum under penalty of perjury one of Me fo mg decla ilmos:
❑ 1 have and will maintain aCerufieute of Consent to self-made for Worker's Comped -
a mon, as provided for by Section 37M of the Labor Cade, for Me performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of Me labor Code, for Ne performance of Me work for which this permit is issued.
My Workers Compensation Insurance Maim and Policy number am:
Cartier. Policy No,
, '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thtssection need not he computed dine permit is forma, hundred dollen ($100)
,
or less.)
I certify that in the perfumerµ, of Ne work for which this permit I. issued, l shall not
employ any person in any toted bst ri•ia�abdEmrc mbiacuo Me Worlaw'Compansavon
Laws of Califp '.DmK `ate""`" H]N✓
Applicant' j,/ d(OIa`
NOTICE TOA PP LICANT: of Exemption, odyoushould
Corrmaking du irons
becomes N t the Werh a of
Compensation previsions of Labor Crile, you mull
foMwil reply with such provisinus or this permit shall be deemed nwokcd.
y pe
CONSTRUCTION LENDING AGENCY
1 hereby alfum Our thtn I.. command Ita ding agency or Me performance of
Me work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Name
Lender's Address
I reNfy Nat 1 have rad this application and state dust the above informadon Is
cancel I agree to comply with all city and county ordinances and sok laws relating he
building concoction, and hereby authorize representatives of this city to enter upon the
for inspection purpowhich ea.
above-ms,judg A propertycosts
(We) agree to save, indemnify and keep handless ft City of Cupertino against
ert. may in any way attme egelmtaaid City
ts,Me dof
inconsequence f grantingthis uwhich
Aconsequence of the grsming,(this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S C EGULATIO
Re -roofs
Type of Roof
& zoep
_
Signature ofApplicaHAZARDOUS MATERIALS DISCLOSURE Data
Will the applicant or future building uccupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
ode. Section 25532(a)7
r7 Yes p/Nn
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the appEMm or future building account use equipment or devices which
emit hazardous air contaminants as defined by dm Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yin a
I have mad Me hazardonmatenab requirementsunder Chaptees.95 of the Califon-
ria HMIM& Sefety Cort,, Sections 25515.25533 and 25534.1 undenMnd thmifthe building
_
j
now not currently have a trent. Mat it is my responsibility at notify the o cupact of the
r
m which most be nor issu a Ccrifica¢ FOcpupaiy,,
' --�1 VN
Signature Apphc
y� Pod-J�Nl�z'
/
of rat to
All roof coverings to be Class "13 or better
Owner tar auMonzcd agent Dam
Please check applicable subcontractors and complete the following informMinn• "
60
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
Date
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 �c�viva2d
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). l
Property Owner's Signature: ! J Date: 114,, Zri o 4E
Job Address: Zwr r AA )PA W,09- Q� Permit # DZ%$
AM changes to the information provided on this form shall be submitted to the City of Cuyertino Build
• Devartment.
Dear Property Owner.
City of Cupertino Building Department
10300 Torre Avenuq
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 compensa i
ov
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 the verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed an Recycled Paper
�CITY OF
UPEI�TINO
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 comply with the above stated policy on re -roofing.
Homeowner'sNae: plaejWtt Po ulSb
Job SiteAddr`�d: /D��c'r" /tri.irA-V/M/4 JZD'
Roofing Company N e: len
A plicant's Signatyr;�:
• Greg teel
Building Official
aM./ ,,,i�LAVW-
Revised 1/30/03
Printed on Recycled Paper
r1
LA
•
ano
CUPEkTINO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
�Cpv�d2.1-�
APN #Date:
3�-7 6 Z
o
BUILDING
__q
Building A ess:
BUILDING
BSEISMICRE
Seismic Fee Res
&6&r
BSEISMICOM
Owner's 1�me:
BUILDING
BPLANCHK
Phon #:
BUILDING
�r
Business License
S" S"
Contractb4
o e #:
License #:
Contact:
Phone #:
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
13 Asphalt Shingles
)Q 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 Polic : ❑
Job Descripfiph:
d4ab
41��
e
-Ild
j r'eolIWA k9tv r171,14 P
Residential ❑
Commercial ❑
guar
Fire Zone: Yes ❑ No ❑
Confirmed with PI ng Dept. i .,
there are any re ictions: LJ
Cost of Project:
tcp000
Typ� s t'
n: Occupancy gr up:
Qty, if
A191'A Eable
Fee m
Fee Iiecrrintinn
RPP r."'.
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
f7T