03100099CITY OF CUPERTINO
a
CONTRACTOB IN '
1 BUILDING DIVISION PERMIT
tY'-
BUILDING ADDRESS:
MANSCH MICHAEL P AND JOANN
ER IT 1103100099
OWNER'S NAME:'
PERMIT ISSUE DATE
JNE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hcrchy affirm that I am licensed under provisions of Chapter 9 (commencing
with Section? MD) of Division Settle, Business and Professions Code, and my license is
in full force and cf Dol.
RER00 F
License Class Lio.k
Dam Contractor.
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
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Licensd eProfcssinnal
OWNER-BUILDER DECLARATION
1 hereby arm Nal 1 m1. exempt from Cc Contractor's Law for the
affirm
/
Co e: An,
reason. ]1131.; Business and Code: Any city or county
/v
dimmil
which requires a permit reconstruct, alter, improve, dcmnnitt or repair any structure
which erten t improve,
requires Ccapplicant far suchpermit to Glaa statement
prior h5its censed
Sq. F[. Floor Area
Valua[lon
palm
pursuant to the nr the Law
thathe is tohe (ChapterCode)
eBusinur'snd Proelaw
info Codc)or
mecing with of Division Or
(commencing xewith Semiconn 0apand of Division3 of theeudamandus.
An
Cat he is exempt Cercfrom and Ne baso for Or alleged caempsion. Any violation of
APN Number
Occupancy Type
Scction 7031.5 by any applicant for a peons subjects the applicant to a civil penalty of
not more than five hundred dollars (150)).
❑ 1, as owner of the property, car my employee with wages as their sole compensation,
305 - FRAME Required Inspections
will do the work, and Be structure is not intended or offered far sale (Sec. 7044, Business
end Professions Code: The Combacmr's License Law docs not apply to an owner of
property who builds or improves Cercon, and who does such work himself or through his
307 - INSULATION
tun employees, provided that such improvements are not intended or offered for sale If,
601 — ROOF TEAR OFF
however. the building or improvement is sold within one Year of completion, the owner-
builder will have Ce burden of proving that he did not build ar improve for pmpoic of
6 02 - ROOF PLYWOOD NAIL
ale)'
603 - ROOF BATTENS
❑ 1,ru owner Property, exclusively confessions with licensed eonrracturs to
construct th ej ct , Business and i The Convector's Li
not (Sec. ]
6 04 — ROOF IN-PROGRESS
oes property who ds or
canoe Law does not apply m an owner of property who builds or improves Centra, and
an wneo
whocontractsLasts for such projects with a contractor(a) licensed pursuant to Ce Convectors
License Law.
1 am exempt under Sec. . B & P C+for this reason
,
r Data � ja
HIS R'S COMPENSA'r 7 DECLARATION
I here rpenelfy of perj oonne or the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCompen-
satirn, m provided for by Section 37W of Ce Labor Code. for the performance of Ce
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 or CC Labor Code, for CC Performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy Ne:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This archon need not he completed Ethe Permit is for one hundred dollars (51 W)
nr las.)
1 cenify Cat in the porrorm ucc of Cc work for which this permit is issued, I shall not
empleyanypersvaio/nyrommor x as a hecomesubject to the Worked Compensation
Laws of Califo�NWsii�gjsasc y),%ix�.
ApPli t
_
NOTI APPbI ANT: IL aft r making this Certificate of Exemption, you should
baso jest m the rkcfa C mpecaution provisions of he Labor Code, you most
forthwith comply with au row ions nr this permiuhall M ticcmcd mvnkcd.
CONSTRUCTION LENDING AGENCY
I hereby affum that more is a construction lending agency for the performance of
tM work for which this permit is issued (Sao. 3097, Civ. C.)
Lender's Name
Lender's Address
I eagree that I have read this application and sure above information relating ix
comply with City Nd county ces and lensr
building onamto
ernNlnBrce98nd ityture
upon the
on,end hereby anthorivercprescnmtivcs of this city l9 soler upon Cc
y
above-mentioned
about-mentioned propcny for inspection purposes.
(We) agree to save, indemnify and keep hay in an the City of Cupertino against
which may in any way acctuc against said City
costsandof
Hatulinconsequence
free thisexpenses
of Cs granting of this permit.
/
Aconsequence
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULA IONS.
Re-roofs
Si mcofA anUC rar r Date
HAZA US MATERIALS DISCLOSURE
-
Type of Roof
Will the applicant or future building Occupant store or handle hazardous mnerial
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(e)?
All roofs shall be inspected to any roofing material being installed.
❑YCS
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or for.. building mempunt use equipment ter devices which
it hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
strict?
❑Year
I have mad the h ommous materials requirements under Chapter 6.95 of the Califon
pia Health lk Safety Cole, Sections 25505,25533 and 25534.1 undersand that ifine huilOng
I
does noti rumor, that it is my respor w notify the mcuPanf of Ce
a Ccm
require nw ichmusbcmelpdonoissuanaoraCeniG ofOcc�,an/�J
Signet eo 'ant Date
G!llJ�
All roof coverings to be Class "B" or better
Owdr
or arm ei,ed agent Date
t
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: CEIVED
OCT 1
A. _ All of the work
B. _ A portion of the work (complete section
Contractor
Address/City Phone #
State License # Type of work to
be erformed
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 5idp).
Property Owner's Signature
Job Addreo: , NZZ
IDepartment.
AVL
Date: OLI,
Permit # 010_ C
1
(.
CIN OF
CUPEkTINO
Dear Property Owner:
City of Cupertino Building Del
10300 Torre
t
�l
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 Califon -da 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 govenuneni 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 compensation•
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 on Recycled Paper
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CITY Of
UPEkTINO
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
Homeowner's Name:
Job Site Address:
Roofing Company Name:
with the above stated policy on re -roofing.
J A
S �Elv_l,vso),on_ JWP
,v
A plicant's Signature:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Date: / 0 01 J2
a ,
OCUPEI�TINO
i
•
CITY OF CUPERTINO b 3 o S
REROOF
PERMIT APPLICATION FORM
APN # _V__4,11
10 u2
BUILDING
Date:
v
Building Address:
]
Avc
Owner's Name:
�AVSGIa
BSEISMICOM
Phone #:
Ud I
Contractor:
Phone k
Plan Check Fee
License #:
Contact:
Phone #:
BUILDING
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt ShinglesAsphalt
Shingles
Ir Wood Shakes
-Wood
❑ Wood Shakes
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 Policy:
Job Description:
_.
4---"
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Residential
Commercial
J5 O R
Fire Zone: Yes ❑
N
Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project:
Type of Constructto
Occupancy group:
Qty. if aa
ADDlical) Fee ID
Fee Descrintion
Fee C',rnnn
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
23 q6`
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