08080104 CITY OFkCUPERTINO � -
BUILDINcbivlsioN" PERMITIT
GILDING
bis'I
BUILDING ADDRESS: PERMIT NO.
10434 PARADISE OR DAN ELLIOTT' S ROOFING CO 08080104
OWNER'S NAME: PERIAT ISSUE DATE
1?I.000NE EDWARD 'C AND SYDELL K P 0 BOX 26878 08/14/2008
NE: (408) 559-7327 SANITARY NO. CONTROL NO.
ARCHIECrMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O
300 LICENSED CONTRACTOR'S DECLARATION IOW Description
rcl 1 hereby.flim pat 1 sen Ikeoad under provish w of Chapter 9(mmmcncing p
with Section 7001ro'Divman S offs Busnea and Profehaklts Code,his my lkesse u RE-RF RMV SHKS INSTL OSB #30 FLT INSTL 40YR
^� in fullf • a7.
i� License ow
or��.Cmc �S Lk.g_r a /-3S S' DIMNSL
7 Dao: - canuu =
e
ARCHITECTS DECLARATION FBRGLS ALL NEW MTL CLS A 26SQ
L I understated my plans"I W uxd is Public reeaNa
p
k 5 Licensed Professional
b —1 resOWNER-BUILDER DECLARATION
O9 1 hey.(Tien that 1eumpt from the Contractor's Licence Law for the
D o following n.(Buchan 71131.1..5,Business area Pwwsaiom Code:Any city of county
$ reniwhich requires a permit a emaVuel,aper.Improve,moralism.W,w mash any umctvro
x>
prim wiused issuance.Wont Wore the applicant o for suhpctor's ice=fie a Lns(Chaptsurmount
zFp<
(that we commencing
lkgwithSscoemw0epmvisawofthe oftheBsinessh dProwaw(CMPLLn9 Sq.Ft. Floor Area Valuation
3$
that
hherfro and ofDimf3oftheBwinexempton.myviCode)or $8767
3 fec he 7 31.5 b say cep li and ort aper for be alleged exemption.to My it promon of
Section than five
arty applicants claims
s(a petit subjects the applicant &civil penalty of Number Occupancy Type
not roamthannveemedredddrm(gm) 35916026 '°�l� _
❑I,peowmreftliepmptq,mmyemplaymwithwlpssufeucokcompemdm,
wiHdo the wrk,and tMswcwm r mtimm�d woffmd torsade(Sce 7044,Buainem
and Professions Cade:The Commutes License Law dm not apply w an Owner of Required Inspections
property who builds or improve.thermn,and who clearance work hmalf w through his
awn employm,provided that such improvements tie nut intended orolfmad for ode.If.
however,the building wimproven mt r cold within ow year of mmpl mm.the.
auilder will have fns burden of proving that M did me Wild or Improve fns fourpo n of
hale.).
❑1,u awner of the property,am exclusively cemae0ng with licensed comacun to
mnstmct the pmjen(Sec.7044,Busineu and prolamines Code:)The Conmeun's Ll-
roue Law dm not apply to an owner of property who builds or Improves thenew,and.
who comsat,formula projects with a mnuacbr(q licensed .at to the Conolnces ,
License LAW.
❑Iamexemptunder See ,B&PCfwthiarcpem
Owner Data
WORKERS COMPENSATIONDECL RATIGN
I hereby aBim under penalty of Perjury now of the following detanfmtc
I have and will mdnWn a Certificate of Consent In alf-imme for Worker Coupon•
nation,as provided fns by section 3700 of the Labor Code.for the Performance of the
work for which this Permit is humid.
❑1 haw and will maintain Woftes Compensation Insurance,as required by Section
3700.1'the Labor Code.fns the Pere .me afthe wort fns which this permit is lamed. '
My
war trr Campc" mInwranax cca�mr//e//w��and Policy number son:
tarter.
3�a e NOLPolity No.:
CERfIRCAIft OF EXEMPTION FROMW IC�ERS'
COMPENSATION INSURANCE
(Thr.roti.need inn be completed time Permit ufw.nehohmed duRm(SIM)
what)
1 testify that In the performance of we work for which this permit is wanted,1 shell not
employ any pnfcon in my...,an as w became subject to the Wmims Cumpenafan
Laws of Cadif ods.Dau
Applicant
NOTICE TO APPLICANT:If.afar making this Cer ifate of Exemption.you should
become subject an the Wmka's Compensation premium of the labor Coda,yen muss
.JO forthwith comply with such Provisions w m
this permit shall x deemed worked.
z 0 CONSTRUCTION LENDING AGENCY
[+ l hemby drmm that them is.eom uctlon lending agency for the performuhaN
LYi> fn wit fns which this pemlt r iaued(Sec.3(197,CN.C.)
W Lender's Name
aZ IsndAdd.s Add
1'J 0 1 certify that 1 have read this application had suss was the above information is
iy^ correct.I agree m comply with all city and county wdinuhas and me laws testing m
0 SE building construction,aM hemby mutation rtprennutiwa of this city to motor upon the
{L7 above-mentioned property fns inspection purymes
gy (We)agree waw,Indemnify and Wap harmless the City of Cupertino&Saint
liabilities,judgments,cam and expenser which may in my my&curve against aid City
C.)7 in conaquma of the granting of this pet L
r1• APPLICANT UNDERSTANDS ANN)" COMPLY WITH ALL NON-POINT Issued by: Date 6 'I -�•
souR EcuyTl%s Re-roofs
Signatum of ApPliunuCanuscwr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII fm applicant or
futum Wulltng P.t..tussock hament msudal
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code.Section 25532wn f')[ya� All roofs shall be inspected prior to any roofing material being installed.
❑aNYen T\
Will the applicmt ar future building Occupant tae equipment w dcvlm which If a roof is installed without first obtaining an inspection,I agree to remove
lave
1i hunw oaf cmatmi...u u dclined by the Bay Amo Air Quality Management all new materials for inspection.
District?
❑Ya 4N.
1 have mad the hahardmc materials commmmu undo Chaper&95 of the Califor-
niaHenith&Salcty Cede,Sx6002550.5,35533md25534.ImdcmmdthuifNe building
dm Out cumendy haw a mnml that it u my responsibility w notify de mxupmt of 1'e
wnrwhehmuubeme wi pewee Cmulkaw.1Ocapeey. Signature of Applicant Date
rrA'c�J � 8-/9 All roof coverings to be Class'W'or better
Ower of awhedsd agent Dow
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35916026 . 00
DATE ISSUED. . . . . . . : 08/14/2008
RECEIPT # . . . . . . . . . : BS000005790
REFERENCE ID # . . . : 08080104
SITE ADDRESS . . . . . : 10434 PARADISE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PICCONE EDWARD C AND SYDELL K
ADDRESS . . . . . . . . . . : 10434 PARADISE DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2914
RECEIVED FROM . . . . : DAN ELLIOTT ROOFING
CONTRACTOR . . . . . . . : DAN ELLIOTT LIC # 21466
COMPANY . . . . . . . . . . : DAN ELLIOTT' S ROOFING CO
ADDRESS . . . . . . . . . . : P 0 BOX 26878
CITY/STATE/ZIP . . . : SAN JOSE, CA 95159
TELEPHONE . . . . . . . . : (408) 559-7327
tFEE IO UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- --- ----------
1BSEISMICR VALUATION 8, 767 . 00 0 . 90 0 . 00 0 . 90 0 . 00
1REROOFRES SQ FEET 26 . 00 338 . 00 0 . 00 338 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 338 . 90 0 . 00 338 . 90 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 338. 90 #13398
---------------
TOTAL RECEIPT 338 . 90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- --- ------------------ -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
0lo(
CITY OF CUPERTINO
REROOF
*UPEkTINO PERMIT APPLICATION FORM
Date:
Building Address:
\ova 'Oh Hca %C z � �\
Phone#:
Owner's Name:
License#:
Contractor: c ( hope#: � 3Z� � ` � '3?>
o S 00 Phone#: Cupertino Business License#:
Contact:
� S2 �{O1�1-`39
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles n \ I _ ,
El Other(Specify) ❑ Other(Specify) 1 \D 1 f I9 S�\' 0,
Number r existing coverings 0 R t= [3 Provide I.C.B.O.Report# ASTM D y O\$
❑ Provide Mfgr.Installation Specs.
® To be Removed
I Have Read,Understand and Will Comply With Cu ertino's Tear Off Polic : —�
Job Description: TQmov� sha�G2S\ t °` �� t ��s a1\ oS3 t3a
corn ln\-e 2 s\-a\\ o en d\\^c�Rv\stohal d'�bec r a\\ re,�
Residential Commercial ❑
Fire Zone: Yes [I No [� Confirmed with Planning Dapt. if
there are any restrictions: LJ
Cost of Project: d Type of Construction Occupancy.gro
Qty. if Fee Description Fee Grou
A licable Fee ID
ERMFEE Bid Permit Fees BUrLDING
BENE rnergy BUILDING
BSEISMICRE Bei ' BT TH DING
BSEISMICOM ' Commercial BUILDING
Bp Plan Check BUILDING
BUSLIC Business License BUILDING
e�oo r
Community Development Department
Building Division
City of Cupertino
• 10300 Torre Avenue
Telephone: (408)777-3228
Fax: (408)777-3333
CUPEI�TINO 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 obtainin galltiinspection
an
and written approval from the building inspector. Afinal�pe re roofing
approval shall be obtained from the buildinginspector
is completed.
3. All roofs shall be inspected prior to any roofing installation.
¢. To receive a final sign off from the City,the following steps are
required:.
1) pre-inspection and/or tear off approval.
2) h1-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_isapplied 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 isnot ready,
you will be charged axe-ii fee of$176.18., The,re-inspection fee must.
be aid before another ins ection can be scheduled
impb
1. Flat roofs must have a minimum of.'/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 undersfand and will comply with the above stated policy on re-roofing.
Homeowner's Name: e`S y l \,C GOYI (J
Jo �Oy3y �wrt>` cl�s2Dr(\�y-��^
b Site Address: �It ,��5 0 aT `•-�
Roofing Company Name:
•
Date:
Applicenfs Signature:
ur
Greg Casteel
Building Official
Revised 11/2/04
Community Development
10300 Tone Av==
Cuperfino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
ci
UPERTINO
Buildin De artment
JOB ADDRESS: PERMIT#
1C)W3Ll
OWNER'S NAME: cca a PHONE# S'I -2q0
GENERAL CONTRACTOR: o flavx� FAX# L(O`b-'5 Sa
kj2oo�er
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and co m Tete foil win information
SUBCONTRACTOR BUSINESS E 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
® S -\4-02
Owner/Contracnature Date
POLICYHOLDER COPY
NF
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-28-2008 GROUP:
POLICY NUMBER: 1884808-2008
CERTIFICATE ID: 73
CERTIFICATE EXPIRES:01-01-2008
01-01-2008/01-01-2008
NF JOB:ALL CALIFORNIA OPERATIONS
This is to certify that we have issued a valid Workers' Compensation Insurance policy In a form approved by the
California Insurance Commissioner to the employer named below for the policy period Indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be Issued or to which it may pertain, the insurance
afforded by the policy described herein Is subject to all the
terms, exclusions, and conditions, of such policy.
• HORIZED REPRESENTATI PRESIDENT
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #2088 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2008 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
® ELLIOTT, DANIEL F. (JR) NF
PO BOX 28878
SAN JOSE CA 88189 -
[WO NFI
PRINTED 01-28-2008
(REV.2-061