06030009 (2) CITY OF CUPERTINOaf: e -
BUILDING DIVISION PERMIT CON', R�INFO,RMATION
'BUILDING ADDRESS: PERMIT NOQ 6 0 3 0 0 0 9
04
OWNER'S NAME: FERMITL$UEDATE
LIU DAPHNE 03/03/2006
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED C0NTRAC10R'sDECLARATION IobDescription
dr 1 beroby affirm that 1 am formed under pmvitiov of Chep.,9(rommenhing
wird Sa0on 7M)of Division 5 of uc B udrcas and Profession,Coda,and my license u
a)'� imm�farmAndefrm REPLACE EXISTING SHAKE ROOF W1 CLASS. A OR B TIL
t � LmenrcClm Lk.g NEED CONTRACTOR INFO
Dam ARCHContracITECTS
L
ARCH)ItsmSDECLARATION
1 understand my plan Nall be usetl As public raords
y IL Licensed Pmfersinnel
ga OWNER-BUILDER DECLARATION
4 c Z I hereby.Ilion on I em Attempt from W Contractor's Co License c Law for the
E D o following common.permit
u 78713,Business and Improve.
desav Gado:My city or acute
vtl$ which required s permit re mn,uucL After.impms o k ok permit
W.ri n,pilr my structure
pdor inat he
emseed eatso mquin,etbeisions of forthe onnermttm0le a,Law(ical ststemen(
< (comm iscingwitpureumlmthe of Divan.of theeBomeass Llcenselaw(Chapter9 Sq.Ft.Floor Area V81U8t x000
(commencing arafmaion 7000)ofbaWon3nftheeged exaaad pton,MynnsCadle)Or
donof
3 (hat he is 31.5 b themfmm and the burs it the allcia the eumant to MY it penny a(
section a thato w airy Applicantfara permit mbjems W Applicant m•rival penalty of ATN Number Occupancy 1)rpe
ootmart than rtes hundred dollars(55001 35703071 . 00
❑1,u owner of rhe property,or my employes with wages u(heir Role mmpeaullon,
will do the wok,and themucone is not intended or offered formic(Sm.7044,Busmen Required Inspections
and Proproperty
who
h bis Cade:The ContrucmsdWmn,and
who law dam not apphim ir sn owner of q T
propertywhomilds arimprot inIh impr andwasdes aimwak hooffredWaugh his
ownemployees,provided posuch Improvementsartmt ear of araRrnd for Wei(,
builder,des building or den of provinis Roll within oro year of mprove for
the use of
build!will have the burden of proving Net be did set build or improve far purporc of
ale.),
p�'II u.weer of the property am exclusively contracting with licensed mmrRomn to
fotsmuc(dte pmpact(Sac.7044,Business and Profession Cade:)The Comrana/s U.
marc law dma om apply w an ower of pmperty.who beim.v improv ft..and
who contracts for such pmjecu with a eantractaNU limned pursuant to W Conuacmr's Q/
Lhienrc Law.
❑l am exempt uad=Bee. B d:P C for this mason/
wnr + Date 3- 3 -�E+
5 COMPENSATION DECLARATION
1 hereby affirm under penury of perjury ane of W following declan0av:
❑1 haw and will maintain aCeNnate of Covent to self-mum far Worker's Compen.
fallen,as provided for by Section 3700 of the Vber Code,for the performance of the
work for which this permit Is Issued.
0 1 haw and will maintain Worker's Compensation Insurance,an required by Section
3700 of the lobarCode,for the performance of W wok forwhich this permit Is Issued.
My Worker's Compensation Ivummem carrier and Policy number am:
Carrier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Obis secdm(wed not becompleted If the permit Is foronc hundred dolim(SI00)
fir Itch.)
I certify thal in the performance of des work for which this pesmll is issued,I.lull mat
employ any person In my masse!m Y an bccc aw N!b*IO me Wokers GOrllpenLdnrr
laws Of Cali in.DR
6
Applinnl
NOTICE T)APP CANT,If.after making this Ce tillme or Exemption.you should
become mhien the Worker's Compensation provisions of the LJber Cade,you most
,JO forthwith comply vies such provision or this permit Nall bedttmW revoked.
,�.r tiCONSTRUCTION LENDING AGENCY
F' I bemmy Orirm that than,is a construction lending agency for the perfarmmce of
tri v�.r the work for which this permit Is issued(See.3097.Civ.C.)
Q Lamleta Name
=z Lender's Address
U Q I certify that I haw mad this application and taw that uc abew information u
{I.!+ torten.I agree to comply with all city Rod county ordinances and sum law mining to
C) building construction,and hereby auuoriw representatives of this airy to anter upan the
{57 shove-mentioned property far Wpec0an pugmsea
Lkr (We)acme m raw,Indemnify and keep harmless the City of Cupertino sgaivl
cn liabilities,judgments,cats Rod expenses which may in my my amus against said City
t.)7 In covequevc of Na grmling of this roman.
Fi APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
IOURCE�E-AV MS
3'3 "6 Re-roofs
Sigmurt of AppliaZDaw
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the aApplicantsCupertino
no forum building occupant atom or handle h Health
anmateriil
M defined by the CupeNno Municipal Code.Chapter 9.11.and W Hcilth and Safety
Cade,Section 25531(.)7 All roofs shall be inspected prior to any roofing material being installed.
lk Dyes (a No
Will the applicant or future building Occupant tax equipment or devices which If a roof is Installed without first obtaining an inspection,I agree to remove
cm t hnardnus air contsmin,me As defined by W Bay Area Air Quality Management all new materials for inspection,
District? ,,//
❑Yea .r_INu
I have mad the muardnusmateriW requirements underCluperd.95 orthe Califon.
amRalPkSafelyCode,Sections 15505,25533 and 15534,1 understand matifthe building _ 3 - xv L
does not currently haw a wnanc uat It is my responsibility to notify Be mupant or W'
myvimm nuwhich Must bemm prior m tssuanceof a cekricate of Occupancy. Signa Ure Of Applicant Date
C ; e I -3 6
Owner or Submingigma - Dam
All roof coverings to be Class"B"or better
CITY OF CUPERTINO -
1• 1 of 1 PERMIT RECEIPT OPERATOR: bethe
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35703071.00
DATE ISSUED. . . . . . . : 03/03/2006
RECEIPT #. . . . . . . . . : 33430
REFERENCE ID # . . . : 06030009
SITE ADDRESS . . . . . : 10428 S FOOTHILL BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LIU DAPHNE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2604
RECEIVED FROM . . . . : DAPHNE LIU
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ ------------- ---------- ---------- ---------- ---------- __-___---_
BPERMFEE VALUATION 7, 000.00 137.16 0.00 137.16 0.00
ESEISMICRE VALUATION 7,000.00 0.70 0. 00 0.70 0.00
__________ __________ __________ ----------
TOTAL PERMIT 137.86 0.00 137.86 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ ________-__-_---_-
OTHER 137.86 VISA
TOTAL RECEIPT 137.86
•
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
nCITY OF
C�T'A IO Fax(408)777-3333
1 C t Building Department
JOB ADDRESS: PERMIT#
o d. svfc ,`16� 30o0
OWNER'S NAME: ,P PHONE #Cv o - 666G
GENERAL CONTRACTO : 2 FAX #0i�o b''J
I am not using any subcontractors
Signature �— Date
Please check applicable subcontractors and complete the following information:
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
v/ Roofing fit ye0T•n
Septic Tank
Sheet Metal
Sheet Rock
Tile
3-3 - � 6
ontractor 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 portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be CtfV1113Gd
• 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 Signa — = - Date: 3
Job Address: /o 4e�LS- r e I-Lp 191adK76- r.4%,f o a Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
City of Cupertino Building Departnien
410 10300 Torre Avenu�
C U P S p'T'I A 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 compensatio*
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 forst 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 Department
Building Division
M City of Cupertino
i 10300 Torre Avenue
one: (408)777-3228
CITY OF TelephFax: (08)M-3333
�UPE(�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 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.
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
be paid before another inspection can be scheduled.
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's Name: ! ) �,.o hn e
lob Site Address: A (,5� S . "IL(I ���. ��e,�•�v /� f`°/fC
Roofing Company Name:
Applicant's Signatu - 1 _ Date: j"-3
gl `—�
• Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: hone#:
/
Contractor: Phone#: License#:
Contact: � Phone#: Cupertino Business License#:�eo �� ��s sale
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
IV Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings X Provide I.C.B.O.Report# 2•
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: El
ob Description: I
Residential Commercial E] -{-- Lv-- ro
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: IJ
Cost of Project: f7 Type of Construction: Occupancy group:
Qty. if
Applicable 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
•