05010085 (2) FBUILDING
tTY OF CUPERTINO BUILDING DIVISION PERMIT = C®NTRAC"TOR£INF®RMATIADDRESS: HERITAGE CONSTRUCTION AND PERMITN005010085
21972 MCCLELLAN RD
OWNER'S NAME: - PERMITISUEDATE
MASAKA OTSUKA 113622 SARAVIEW DR 01/13/2005
ONE: SANITARY NO. CONTROL NO.
(408) 379-2005
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
10, LICENSEDCONTRA SD LARATION
igu❑ Wrcb firm mal l em littnxa under sions of Chapter 9(commencing Job Description
with Sem )of olv. n of NC Busi olessiumcodia.and myliccmcis
in
icanr aerrea "' C KIS 5J2 REROOF W/COMP. G�j
j�� License Class Lic.N
,Fa Dow Cuntnclor
ARCHITECTS DECR
f�< ndemand my plana shall he ud m pub m rccn s�{.
su Uccn uWq ssonal T\
g 5 OWNER-BUILDER DECLARATIOI'!. v`\
A<f I hereby aRren that I am exempt from the Comrmmfs Lkenu Law for the v
-O o following mason.(Section 7031.5.Business and Professions Code:Any city or county
<m which myuires a permit ro cenuiter,.Iter,improve,demolish,In repair any structure - $4500
uZ j, prlorlo its ismanec.also requirm the applicant rarsuchromottofleasignedsrstement
ss<
that W is licemsedi pursuant(a Vic provisions of Vic Contractor's Licensc Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7")of Division of the Business and Professions Code)or
Oak he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70]1.5 by any applicant for a permit subjects me applicant to a civil penalty of Gr00 Occupancy Type
not more Nan five hundred dollars(3500). p Y Yp
o I.as owner or the property,or my employees with wages as their sole compensation,
will do the work,and due swaum is not intended or offered for sale(Sec.7000,Business
and Professions Code:The Contractors License Law duos nut apply to as owner of Required Inspections
property who builds or imgo es dumor.and whodoes such work homelier tMugh his
own employees,provided that such improvements we not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,Ne Owner,
builder will have the burden of proving that he did not Wild or improve for puryose of
ink.).
❑1,as owner of the property,am exclusively comma ing with licensed coruacrom to
construct the project(See.7W.Busineu and Professions Code)The Contractar's Li
came Law door not apply to an owner of property who Wilds or improver theuon,and
who contacts for such projects with a Commonly)licensed pursuant to the Convenors
License Law.
❑I am exempt under Sec. ,B&P C for this mason
wrier Dow
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one or the following declasniom:
I have and will maintain a Cer ifimm of Consent to self-imam for Worker's Compen.
ration.u provided for by Section 3700 of me Labor Code,for the performance or the
work for which this permit is island.
❑1 have and will maintain Worker's Compensation Insurance,az rryvired by Section
]7110 of Vic labor Code,for doo performance of the work far which this Permit is issued.
My Workers CnmPemuion Insurance carrier and Policy number art:
Carrier: E' �d.J�1�.Policy No.: V
C NE OF F-X' PTION FROM KERS'
COMPENSATION INSU
(This section nod not heewnpincJ If the permit is rmonc hundred dollars($100)
or less)
I unify mat in me Performance of the work for which oris permit is issued.I shall not
employ any pmsen in any manner in as Or hecome wbjcn to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker'.Compensation provisions of the Labor Cosic.you main
�z rorthwi th comply with such provisions or this perm it shall W deemed revoked. -
z'vy CONSTRUCTION LENDING AGENCY
1 W mhy offrm mat them is a connmminn lending agency for the Performance of
Ys the work for which this permit is issued(sec.3097,Civ.C.)
Qlenders Name
7 z Leaders Addma.
J 0 1 Certify that 1 have mad mil application end sure mat the above information is
y t-' comet,l agree to comply with all city and county ordinances and state laws relating to
0building construction,and hereby authorize mprcuntalives of this City to Inter upon are,
[,
U ahovc-mentioned properly for impeetion purposes,
gy (We)agree mrcm
,indemnify and keep harmless the City or Cupcnino against
h ( /
liabilities,judgments,costs and expenses which may in any way wens,against mid City
;)z in consequence of rhehegraining of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE ULATIONS.
�O1^ C�r Re-roofs
SignatureofA licant/Conuumn Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WillmeepCu,nwrToroth buildinge.Chaptmomor handle ha Uvad Safety m de,Seo by the Cupertino Municipal Code.Chapter 9.12,end me Health and Safety
otic,Section 355J1(a)?
❑Yin 91,,10 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or metre building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardous air contaminants as defined by Vic Bay Area Air Quality Management all new materials for inspection.
Wrier?
❑Yes fl Nu
1 have mad the ha aNnm7materials mquiremenm under Chapter 6.95 of the Colton,
nixdo HalmurBalmyCve&remand,
itI35533 MYMSIP755N.l Mnoury thcim'rol or do
dam not Currently have a mnank mat it is my respomihiliry m(roti fy the occupant of thej-
mi; mCallwhichmustWmetpnorOrissurre.ofaCcamCon,a ccupermy. I atore of Applicant Date
I All roof coverings to be Class "B"or better
wrier ur aumoriac agcm p
r Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO �P
Building a artment
JOB ADDRESS: JTAMIT #
OWNER'S NAME: 0 P ONE #
GENERAL CONTRACTOR: F
I am not using any subcontractors:
Signature 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
-'7�1
Owner/ ontractor Signature `�Q Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
VPEI,TINO
Building Department
JOB ADDRESS: /1 // F•RMIT #_
a2to1 C.Qo ,e,(�n _ � t
OWNER'S NAME:' ` ' .--•S ( P ONE #
GENERAL CONTRA
CTOR: -
I am not.using any subcontractors: /
' Signatufe'� '> Date
Please check applicablesubcontractors 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
Roofing
Septic Tank
Sheet Metal t
Sheet Rock
Tile
C n4 ✓�
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U PEI�TINO 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)
_ 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,
willrequire 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.
Homeowners Name: J TS, A— // /
Job Site Address: 19 7 Z- IL�.c r 16 2,
Roofing Company Name s n r_"! � nnJ CA of
Applicant's Signature:✓ " 74l / Date: /O $ f
Greg Casteel
-`
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
gms, RE ROOF , 0
ICUPEICINO PERMIT APPLICATION FORM
APN # 3�_/ b y U 3 Date:
C� 13
Building Address:
e T e
Owner's Name: Phone#:
� o
Contractor: Phone#: License #:
2--
Contact:
Contact: Phone #: Cupertino Business License#:
3 ry,ZS-r>
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles p- Asphalt Shingles
,W 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:
Residential ® Commercial
Fire Zone: Yes ❑ No ❑ Confirmed withPl if
there are any stri ions: EJ
Cost of Project: Type of ons c Occupancyou ,-
Qty. if
A l ab e Fee ID Fee Description Fee Grou
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