05040050 (2) CITY OF CUPERTINOsnk7 "g"4
BUILDING DIVISION PERMIT x�CONTRACTOR�INFURMATIfQN
1.BUILDING ADDRESS: THOMAS J TI ERNAN PERMIT NO05040050
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY OLNO.
41
ARCHITEC IENO1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
o LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby ))of that 1 am IkeuM under provHions of s Cods. 9(commencing
with Section nd paf Division 3ofthe Business and Profesainm Code.and my license is
In full fora and ettea
'�z Ueam Class Ue.g REROOF W/ SHINGLE
1fFf---q DaN Contractor /
,3e7W< ARCHITECTS DECLARATION
y U 1 underuanJ my plats shall be used u public reenNa
.dud Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby,(IUm that 11. exempt from Oe CanuenCo License city
o for the
'aOO
following a, emit o 7I3 1.5,Business and Profession demolish,or
Mycity oraunty
$�
which requites•permit m construct,alley.Improve.demaltsh,or mpmr any RNctum
i-Z Ln itch b its issueaa rH ant to the provisions
of
far tach perm's License
Lewd stsumrnr
gFF< (cocoon ncinSsedpuruammthcpmviviouofofsheBuncrosandPo,elaw(CMpmr9 Sq.Ft.Floor Area Valuat ors
6$ (commenc exempt
Semfrm and tof he Division 7 of al Budnngempt Professions C i,anndar)of
'b+
that he 7 1.5 b Iany ap li and the hula k be alleged exemption.to Any violation of
Section]071.3 by any applicant far a pump subjects the applicant ro a civil peaky of
not roam Wan Ow hundred dollars(35410). 3 9VNfP�Qr)0 Occupancy Type
O I,U ownerof ilia propmy.a my cenployees with wages u thebule compensadan.
will do the work.and the suucem,is not intended aoReed ferule(See.]O/1,Business Required Inspections
and Professions Code:The Continuator,LicenseroN an owner of e
Law does t apply q ns P
propeny w ho builds or improvestlomen,and who dressers work himul f ver through his
Own employers,provided met uch Improvements an,notlnunded oraRered forsale.If,
however,Ne building or improvement is sold within one year of completion.the Owner.
builder will law the burden of proving that les did not build or Improve fa purpose of
esu.).
❑1,u Owner of the properly.am exclusively connecting with licensed contractors in
convect We ler jeer(Sec.7014,Business and Professions Code:)The Conumcmrs U.
cense Law does not apply to an owner of property who builds or improves Ihemon,and.
who convects for such projects with a contrssmr(s)licensed pursuant N the Cantmmoes
License Law.
❑Iwo underSec. ,B@PCfa Ni revert
/ I IC
Ow ne( . t f Dau
WORK 'S COMPENSATION
1 hereby affirm under penalty of perjury ane of the following declarations:
'I have and will mainuin a certificate of consent a aelGluum for warkels compcn.
7C11
vert,u provided for by Sarson 7700 of the labor Code.for the performance of the
ok for which this permit is issued.
1 haw sed will m tin ria Workers CompensWon Insuruce.u required by Section
00 of Ne IJbar Code,for the perlarmance of the wok far whkh Nis permit is iuved.
Wortmes CompensNon Imm�man carrier and Policy number sec:
rtier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Nis sedan mrd not be completed if rhe permit is fm aro hundred dollua(SIM)
or Ica.)
1 anify that in Ne performance of the work for which this Permit is issued.l shall not
employ ,anylit.. nary maynsfa0u IaMcomc subjauo the Worten'Compenudan
Laws offaRfma �TI73ffJ'�
Applic s Q2�j
NOTICE TO APL CANT:If,After making this Canham of Exemption,you Mould
became subject to the Workers Compcnsadon provisions of the Labor Code,you most
.OZ forthwith comply with such provisions Or this permit shall br deemed maker.
7 0
rte., CONSTRUCTION LENDING AGENCY
'r+ I hereby AR mi that data is a Clac.rn7.Che.egcrmy for Nc performance of
a Le work for which this permit u issued(Sen.7091.Civ.CJ
QLenders Name
.7 Z I<Mers Address
t.> 1 ttnily that 1 law read this application and sum that the thaw information is
ty',••' crown.I agree N comply with all city and county ordinances and sum laws misting in
0 iV^ building construction,and hereby authodm mpmsemmlwa of this city to enter upon de.
W ahovamentionrd property for impaction pur)mua
Ly,,gL (We)agree to save,indemnify sed keep homing,the City of Cupertino against
5rA Ilabilities,judgmenu,cosu and expenses which may in any way ansa aping said City
O F71 In eonugance of Ne great of this permit.
APPLlqANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR OUL�DJif�•_ ,f O�
y Re-roofs
Signature of AppllcuUContracur Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will W applicant or forum building occupant part Or handle heurdou material
as defined by Bm Cupertino Municipal Cade.Chapter 9.17,and the Health and Safety
Code,Section:357z(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes /ZNO
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It have mine,air comeminanss u dcnnM by the Bay Area Air Quality Management all new materials for inspection.
witt7
❑Yes e2l"u
I have mW the huardous mamriala rcquimmenu under Chapter 6.95 of the Califor- ^�� - 0
nix Health&entlyhimauc6anshe,It is my u rexhil.1 ustto notify
dthat if ft e occu,buildiny ��-----��
dos not currently have a antes Net It u my mapoulhility,m notify de aceupant of Nc
mphftnutwhichmugbeMCIpriortoissuanceofaCeniOcateofOOrmectSI Applicant Date
Signature of
-Owner orauthorized agent Date— All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
OC10F
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEf�TINO
Building De artment
JOB-7-710,11SPA,h�✓ Dr. PERMIT# 05-0 �Ds—C)
OWNER'S NAME: ' -\-Vwrx s T, PHONE # Ck�-WZ-aZZZ-
GENERAL CONTRACTOR: 56,k FAX # - $'72.— I b 874
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
Roofingl(r _
Septic Tank
Sheet Metal
Sheet Rock
Tile
� 2zz,�,� - v5
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPERTINO
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:
lob Site Address: _M 09 Re!
Roofing Company Name, ^
D
Applicant's Signature:
ate:
Greg Casteel
Building Official
Revised 11/2/04
PHNorl nn Recmied Paner
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child) will perform:
A. Z 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 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
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Informatio verse side).
Property Owner's Signatu YAk —~ Date: CSS
Job AddrePermit# O S� DO,� 0
y12�1 �v1 dw
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
i�r,(a"d
City of Cupertino Building Depirttnei
CITY Of 10300 Torre Avenu
CUPEkTINO 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
Printed on Recycled Paper
T. 30
CITY OF CUPERTINO Mon
��- REROOF 7 :30
CUPEkTINO PERMIT APPLICATION FORM pS- q 5-0
APN # Q� Date: g, Zt�o j
Z l " 0a(1 J't
Building Address:
-7799 �Gt;�bn�tl �✓. ��tho C�- 916019
Owner's Name: l Phone#:
ll�om�5 �, � i2fn�n 40L242LOZ2'Z
Contractor: License#:
SeIF
Contact: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑/ Asphalt Shingles %2"Asphalt Shingles
lm 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 Mfgn Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 0 n�
e"LiAlf�t7f B ,v�,rkc �� PfL�sicf�n�i'<X �Ls�l � s1+1 ro
Residential ConlYnercial
Fire Zone: Yes a No Q Confirmed with Planning Dom. if
there are any restrictions: I�
Cost of Project: Type of Construction: Occupancy group:
# 5co0
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