04050012 (2) u""
;BUILDING
ITY OF CUPERTINO '� •� 5
BUILDING DIVISION PERMIT CONTRACTQRINFORMATION -;
a%ic: ,tea ,•ADDRESS: GROVER DAVID A AND DEBORAH T!"'B"o04-050012
04R2 TE ESTATEq T)R
NER'S NAME: PERMIT ISSUE DATEGROVER DAVIDONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTORS DECLARATION
YmF I hereby affirm that I am fthe licensed i under provisions of s Code. 9(commencing lob Description
SZyI with Semen Mod. er Division Sof the Business and Profcuiuns Code.and my license is
mroummeanderre=L REMOVE SHAKE
p i License Class Lic.a
"=° Dam-Contractor
ARCHITECTS DECLARATION INSTALL OSB WITH RADIANT BAR'R3-ERpAND
p< Iunderstand myplans nail tie used aspublic rccmds RE-ROOF WITH COMPOSITION SHINGLESWAllC.
emu
;LLG Licensed Professional JUN 7 2004
°j OWNER-BUILDER DECLARATION
aS I hereby affirm that 1 am exempt from the Cmarecmr's License Law for the
°° following again.(Sectlun 7031.5,Business and Professions Code:Any city Or county
ywhich requires a Permit to construct,eller.improve,demolish,in repair any structured n n n flwG®A iA'�
Fiy prior in its issuance.also requires the applicant for such permit to file a signed sutment yore.
< that he is licensed pompom hs the prevision of Me Comrectoh License raw(Charter 9 Sq.Ft.Floor Area Valiiatibn
is (commencing with Section 7")of Division 3 of the B usiness and Professions Code)or
to that he is exempt therefrom and We bazu for the dleged exemption.Any.violation of $8735
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
P Y YP
❑ I.its owner of the property,or my employees with wages m their sole compensation,
will do the work,and ate structure is not intended martered for aalc(Sec.7046,Business
and Professions Code:TM Contractor's License Law docs not apply it an owner or Required Inspections
progeny who builds orimprosxs thereon,and whodems such work himselforthmugh his
own employees,provided thatsuch improvements are not intended oroQered for sale.If,
however,the building at improvement is sold within one year of completion.Ne owner-
builder will have the burden of pmving stat the did nm build M improve for p irpom of
sale.).
ED h as owner of the property,am exclusively contracting with licensed conlnelms m
construct Ne project Dec.7044,Business and Professions Code:)The Contractor's Li- _
ceme law docs not apply to an owner of property who Wilds or improves thereon.and
who contracts for such projects with a contracror(s)licensed pursuant in the Convector's
License Law.
1 am exempt under Sec. .B&P C for Nis reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 herby affirm under penalty of perjury one of the following declarations: -
`,/ Ihave and will for
Se Certificate of Me Labor Code.
for
for Worker's Compere
sourest, r providedhicthis
for by Section 3]00 of the labor Code.for the performance of the
work for which Nis permit is issued. .
1 have and will maintain Worker's Compensation Insurance,az required by Section
3700 of the labor Code,for the performance of the work for which Nis permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
free;stttion need not he completed lithe permit is formic hundred dollars($100)
IcssJ
1 certify Nat in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as m become subject to the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to We Workers Compensation previsions of the tabor Code.you mug
,Jz forthwith comply with such prnvisiom or this permit shall W deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
[—ice I hereby affirm that there is a comrucOom lending agency rot the Performance of
(Y the work fur which this permit is issued(See.3097.Civ.C.)
!y Lender's Name
Dz Lender's Address
Q C) I certify that 1 have mad this application and sure that the above information is
H coned.I agree to comply wit all city and county ordinances and state laws relating to
0U building construction,and hereby authmm mprcenuthxs of this city to enter upon the
Y'wabove-mentioned property for impecyon purposes.
(We-)agree to save.indemnify and keep harmless the City of Cupertino against
f'h liabilities,judgments.costs andexpemes which may in any way acerae against said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of Appli<aDow
HAZARDOUS
S MATERIALS DISCLOSURE Type of Roof
Will the applicant or futurebuildingooccupantamrcor handle Health
tand Sated
az acfincd by the Cupertino Municipal GOdL.Chapter 9.13,and the Health and Safely
code,s=eyes zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
�Yce No
wn the applicant or future building occupant erre equipment or d=maa wre=n If a roof is installed without first obtaining an inspection,I agree to remove
M
hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
Monet?
❑Yes ON.
1 have mad the maned..,maarials requirements under Chapter 6.95 of the Califor
-
niaHealth&SafetyCode,Stennm 25505,25533 and 25534.1 undersand that iOhe Wilding
does not cumeody box a¢nam,that it is my responsibility m notify the occupant of the
mquimments which must is,Met poor missuance or acemricareoraapancy. Signature of Applicant Date
Owner err amthmrivad agent Date All roof coverings to be Class "B"or better
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
YG Gt2 ti2vLG4
® 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 joe true and correct. I have read and understand the
Owner-Builder Information rsi
Property Owner's Si�ture: Dates U O
Job Address; (-U Permit#� G�
Any changes 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 Avenuea
C' I p E kT I N O Phone: (408)777-322
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 vourself from Possible liability if that person applies for the proper permit in his or her name.
j 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
Printed on Recycled Paper
• _,,�� Community Development
i J" 10300 Torre Avenue
;t =' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: d. 101-I82 A,-teS PERMIT E)'to
OWNER'S N T` PHONE # e Z5-?
- z
GENERAL CONTRACTOR: FAX #
I am not using any subcontra for . '0 5 U
Sign ture Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Ah Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
AM e
Owner c Signature Date
Community Development Department
ffr Building Division
Z12
s City of Cupertino
10300 Torre Avenue
OUPECITY OF Telephone: (408)777-3228
DT I N® 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.
Homeowners Name: ��� C
Job Site Address:
Roofing Company Name: (/✓C
Applicant's Signatur Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO DW)
r REROOF
1CUPER4Y-TiNa. PERMIT APPLICATION FORM
APN # � �/ � Date: � -
i � 7
Building Address:
0
Owner' me: Phone#:_
C ff �2d ,2-53 - 3 Z 8 Z
Contractor: License #:
Contact: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 'W 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 Policy: ❑
Job Description: C k / Sfi, �V 5 i N ,' // U & t✓i
UO /6 le, l- 'aru"r r.' arm at!
Residential _ Commercial ❑ rC.o
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
C!Wof Pr j c� Cr
c Type of Co tru do Occupancy group:
.�( p
Qty. if
Ap li .lc Fee ID 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