05040086 (2) CITY OF CUPERTINO �'>
BUILDING DIVISION PERMIT CONTRACTOR-IINFORMATION
'GILDING ADDRESS: DAVID MILLER PERMIT 11b5040086
2186 C V
OWNER'S NAME: PERMIT ISSUE DATE
DAVID MILLER
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
G7 0
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
QC I hereby affirm that I am Iisnudi under previsions of Charter 9(commencing
t/ with Section?gMgof Division 3 ofthe Business and Prolos iom Cade.and my license is
inr9uromeand ercea REROOF W/ COMP. SHINGLES
License Class Lic.A
Dam Contrmnor
�'J` ARCHITECTS DECLARATION
J
'i e� I understand my plans shall W used star public innards GL-
yU �j
30th Licensed Professional
5 OWNER-BUILDER DECLARATION /
I Wrehy affirm Nat 1 am exempt from Ih Contractor',License Law for the /
K
p o following reason.(Section 7W L5,Business and Proressioa Code:Any city of county
,ssa which roquims a permit m construct,son,improve,demolish,or.pair any amm
ucro
m�'^ poor In in issuance.Rise requires the applicant for such permit to file a signed smement
that he is licensed pursuant o the provisions of the Conuacwr's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
,r$ (commencing with Section 7f100)of Division 3 of the Business and Professions Cale)or
y _ that he It exempt therefrom and dm basis for the alleged exemption.Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant o a civil penalty of er0 0 Occupancy Type
not mom Nan five hundred dollars($500).
❑Ido wrier of the psapeny, re is omntande am.(Sec.
compensation,
will dom<work,and the awnureisnot s Licensor .dofored far sale(Sec.in a wdeeof
and property
obu Cade:The Cenuarms.and
law dors not apply lf an owmr of Required Inspections
property who builds or improves;dtht ach icon,and who daessmh wad himselfor edthroughWe his
ownhoweemployees,th building
that suchimpm id witarenetimm�dWmoffcrod for mIosm-
Wilimy ,me building brimpww one year
lo.). will new the burden of proving mat he did not Wild or improv for purpose of
role.).
❑1.as owner of the progeny,am eaclusivcly contracting with Rearmed contractors to
construct the project(Sec.7844,Business and Professions Code:)To,Contractor's Li.
cense law doe not apply to an owner of property who Wilds or improv lbemon,and
who contracts for such projects with a contractor(a)licensed pursuam to the Contractors
License law.
Jr l am ezam f rider See �/�/ .—//�}/it B k P C for this mann
Owner \ "oi,- /W Data —/
WO R'S COMPENSATION DECLARATION
I hereby aRnn under penalty of perjury one of the following deduations:
1 haw and will maintain aCer it ate of Consent to self-insure for WorkchCompcn-
saion,as provided for by Section PBD of me Lions,Code,for the perfarmaaro of the
work for which this permit is issued.
❑1 have and will maintain Workeek Co rphoma on Insurance,as required by Section
37W of dm labor Code,for dm performance of fe work for which this permit is issued.
My Worker's Compensation Insurance canner and Policy number am:
Tamer. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Tris section need not W completed if I W permit is for one hundred dollen(5100)
mss.)
1 ca6(y that in the performance of the work for which this permit is issued.1 stall not
employ any person in any manner sn u m Wmme mbjccl m the Workeri Compensation
Laws of Califoryya.Da¢ `*^y 4^ t^ t-
Applicant�una, .n-sod.
NOTICE TO APPLI NT:If,after making this Ccnificam of Exemption,you should
become subject to the Worker's Comp rimmon previsions of the labor Code,you mum
•J Q forthwith comply with such provisions or this permit lnll W rev
,mod.
reked.
'Z'"' CONSTRUCTION LENDING AGENCY
I he eby affirm that fere iso communion lcndintageocy for the performance or
".� dm work for which this permit is issued(Sec.3097,Civ.C)
0 Landers Name
4ndcr's Addrtss
U O I canify,that I haw read this application and stare that the above information is
Is. F cotmct.I agree to comply with all city and county ordinances and some laws miming to
C U building construction,and hereby authonu representatives of this city to cnmr upon me
r W abovcmemioned property for inspection purposes.
G (We)since to save,indemnify and keep hmmlcss the City of Cupertino against
F' h liabilities,judgments,costs and expenses which may in any way acme against mid City
U z APPLeof th. N of this fermit.
ICANTUNDERSTADS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATI NS, s
�u�G� - lr-0 Re-roofs
Signature of Apple nt/Conuaztor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or run=building occupant mode or handle haardous material
u defined by the Cupenina Mu arml Cade.Ch ip t,9.12,and the Health and Safety
ende.&mnn 25532pp All roofs shall be inspected nor to an roofing material being installed.IWNa
70wntWill the applicant or future building occupant use equipment or device,whim If a roof is installed without first obtaining an inspection,I agree to remove
,
it hanrdous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
amict?
❑Yes caw.
1 have rent the haaNnusmaterials requirements under Chapter6.95 of dm Califor
aHcalth k SafetyCoM,Sections 25505.25533 and 25534.1 undrisend thuifthc Wilding
es not currently have a mount.Nat it is my responsibility w notify the occupant of IW
quir nuwhich in xmnprior wi eofaCenlfieateofOcturaney. . Signature it/Applicant Date
/f iOS
or mmmn dagent Data All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS. PERMIT# oS0L14o
/A,? CA/ IGdP�A a P/ rttC l
OWNER'S NAME: PHONE #Wf -JS-S-- /
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors.
ignature Date
Please check applicable subcontractors and complete the followinginformation:
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
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— 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
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
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: / Date:
Job Address: � I?6-? &r-ti' 4nP Permit#
Any chanties to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
i
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C 1 I P E kT I N O Phone: (408)777-3228
Dear Property Owner:
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 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
Pnnted on Recycled Paper
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P Ekl I N O 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
c:- r- 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 ply4wood 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 ii proper City-inspectioii`car'be perfbrmed::I -i'lUr
. 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
.. __: a t::.• e
` - beyaid before another inspection can be scheduled..,,
IMPORTANT:-
1.
MPORTANT: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.
_r I understand and will comply w_itth the above stated policy on re-roofing.
Homeowner's Name: �/u IU
- 1 94
Job Site Address: C), Wl e / �(c�P"c
Roofing Company Name:
Apphcant's Signature: Date: �' �S ` v-s-
GregCasteel
Building Official
-- Revised 11/2/04
.Printed on Recycled Paper
CITY OF CUPERTINO
RE ROO F
$CUPERTINO PERMIT APPLICATION FORM
APN # Date:
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3aS� La C
te e ' arQ ,,.� .. e k . y i
Q�ryer's Name: Phone #:
O/Ve Nil 11 4�4vr ass 1 > J
CoPhone#: License #:
or:
* S
Coniact: �� f„- u i a� Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: - Proposed:
❑ - Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles A Asphalt Shingles
A Wood Shakes ❑ Wood Shakes.
`❑ '' Wood Shingles• ",` ❑ Wood Shingles
❑ Other(Specify) . ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ .,:Tobe Removed,, ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Jo Description-
ce
Residential .a n.. Commercial .Q
_ Fire Zone: =:Yes,(];:_No• = Confirmed with Planning De I. if
there are any restrictions:' u
"._- . Cost of Project: Type of Construction: Occupancy group:
Qty. if
'
Applicable Fee DD 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
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