04090044 (2) CITY C#f1 CUPERTINO - -BUILDING Drv1s1oN - PERMITCONTRACTURIN1�OR NATION:
_ a yds em'
BUILDING ADDRESS: PERMIT N0.
04090044
17-1 RAMONA CT
OWNER'S NAME: PERMIT ISSUE DATE
ENG
E:
SANITARY NO. CONTROL NO.
ARCHITECIYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 retain,affirm that I me lieemed under previsions of Chapter 9(commencing
Zj�yf with Seetiom 7000)of Dlvlsion3 of the Business and Pmfe�ssiun�s.C,o>de,and my license fee
mllmree and eat, C - TEAR OUT RE-SHEET DECK AND 1�EEDP.
iccnse Cbus 'G Lk.s / V
are TSDffr 50 YR. SHINGLE
A.shall
ARCHITECTS DELLA
�i 1 undersand my plans shell he used u public res
Z Licensed Professional SEP 2 2004
OatNEm exempt f DECLARATION
I 1 hereby.(Sere that 11. exempt from Ne Contras Co License Law for the
p O fallowing anon.(Section IIoT Lq Business and Professions Cale:Any city ori county
RI
Z� whipoor t requites a permit to cores the else 1 tfOrsu h Permitdeamlist or made any arunurt
prior m its Issuance,also requires the apPiioor for sock permit m m a,Lae(statement
acnnhcucmnsNpursuant tion7NcofDivisoofthe eRuinesslhmrclaw(Chepttt9 Sq.Ft. Floor Area a
s�$ 'at he Is en{with Section 71and the
Division n 3 of the egad euand Professions Any vi Grade)or
— Net he V eumpt therefrom and the baa for the alleged exemption.Any violation of
Section]031.5 by airy applicant for a permit subjects the applksnl re a civil Penalty of APN Number Occupancy Type
not more Nan foe hundred dollars(SSW).
❑1,u owner of Ne pmNny,or my employer with wages u their sole compeneetion, 35701055 . 00
will do Nework,and she strctum is notimended proffered forage(Sec.7W,Business
and Professions Cade:The Coneacmrs License Law does not apply to an Owner of Required Inspections
progeny who builds or Improves thereon,and who does such work himmir m through his
Own employees,provided Net such impo wtsents an,net intended oraRertd forule.If.
hawewq the building or improwmeet is sold within ane or of complatirm.um ownep
builder will low the human of proving Net he did not build or improve for purpose of
sale.).
❑I,as Owner of Ne property,am exclusively contracting with licensed contractors a
consumer the project(Sec.7014,Business and Professions Cade:)The Consomme,Li.
came law docs not apply to an owner of property who builds or improves Merton.and,
who canuacts for such projects with a contractor(s)licensed pursuant o the Contractors
License law.
0 1 am oempt under Sec. .B&P C for this rtuon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain aCcnlficute of Consent to self-insure far Workers ComKn.
len,u providee for by Section 3700 of the Labor Code,for the perform...of the
work for which this permit is issued.
1 have and will maintain Worlm's Compensation Insurum,as required by Section
"Iof Nc labor Codc.for the performance of the work for which this permit is issued. '
My Workers Compensation Insuran¢carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EKEMP130N FROM WORKERS'
COMPENSATION INSURANCE
(1Tlauctlon need not hccomplered little Permit Ismrone hundred dollars(SIM)
less.)
I certify llm in the permanence of the work for which this Permit is issued.I shell not
employany person in any moor azebeeome rbjmIin to Warkeri Compcondon
Lawaof Celifonto D
Applleant
NOTICE TO RFPli ANT-.If.fine,making this Cmul m o of Exemption.you should
become aubjper to the Worker's Compcnseuon pmvisiom of the labor Code.you mus
.JO forthwith comply win such previsions or this Permit shell be deemed mvoked.
Z"" CONSTRUCTION LENDING AGENCY
[r
4 I hereby affirm that Nem is a contraction lending agency for the Performance of
LY> the work for which this permit is issued(Sce.3097,Civ.C.)
Q Landers Name
Z lenders Address
U O 1 centify Na I Mw mad this appiicadon and sum Net the show information I,
V,Eycorrect.I agree to comply with all city and county ordinances and sure laws relating to
DUbuilding construction,and hereby maboda repsseniatim of Nis city to enter upon to
W .how-mentioned Property for inspection purposes.
C (We)agree to saw,indemnify and keep hameess the City of Cupcnino against
4 liabilities,judgments,coats and opcnso which may in any way game against aid City
In consequence of Ne granting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE�fLAT N .
Re-roofs
ee tG rotorata
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fume building occupant store or handle hauaAam material
as ecfincd by the Cupertino Munic' al Code,Chapter 9.12,and the Health and Santry
Code,Section 25531()? \ All roofs shall be inspected prior to any roofing material being installed.
❑Ye Nu
Will the 2PP1hant or future building occupant use equipnt mem devices which If a roof is installed without first obtaining an inspection,I agree to remove
It bvsrdou air mnuminanu az delmned by Ne Bay Arta Air Quality Management all new materials for inspection.
uiaT
❑Yes Qpld
I haw read the hnardmasmamrialsrryuiamcnts under ChaPerb.95of Nc Cali(nn
nia Health&Safe, de
CWc,Scuom15505.MS33ud2553e.lunrstsnd Natiftie Wilding
dace not canandy haw a 4 nat it is my msponsihility m nouty the accupml of Nc -
quimmcnts wh nor norm is5uancco(a CcNfcateof OccvpuR to APph nt Dat
e
e All roof coverings to be Class"B"or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 5
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35701055.00
DATE ISSUED. . . . . . . : 09/09/2004
RECEIPT #. . . . . . . . . : 26977
REFERENCE ID # . . . : 04090044
SITE ADDRESS . . . . . : 22373 RAMONA CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO -
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ENGELBRECHT KATHRYN S
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . :. : CUPERTINO CA, 95014-2732
RECEIVED FROM . . . . : NESTOR SOHLEIN
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
ID UNITQUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--
BPERMFSE VALUATION 9, 000.00 158.76 0.00 158.76 0.00
BSEISMICRE VALUATION 9, 000.00 0.90 0.00 0.90 0.00
BUSLIC FLAT RATE 1.00 100.00 0.00 100.00 0.00
__________ __________ __________ ----------
TOTAL PERMIT 259.66 0.00 259.66 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ -__________--_____
CHECK 259.66 1488
TOTAL RECEIPT 259.66
CITY OF CUPERTINO
m REROOF
UPEI,TINO PERMIT APPLICATION FORM
7Building
PN#
Address:
223 7,3 moria
wner'sN e: �� / one#:
S
Con acto : # License #:
c�s � .v iti -566-�?92G � 65Oo6B
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
�1 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:
JobDescripfon:
-
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: U
COSLWi
ect: art Type of ct' Occupancy group:
QY• i
A cable Fee ID Fee Description Fee Group
BPERMFEE Bld Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
(4(D°I DCA4Community Development
10300 Torre Avenue
r ?.
Y Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JO2ADD23 R fir+ • PERMIT
0#09004
eta
OWNER'S N 'd 9 r P #
GENERAL CONTRACTOR: Y FAX#
I am not using any subcontractors: o
gnZure 6ate
Please check applicable subcontractors and complete the following information.-
SUBCONTRACTOR
nformation: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
tractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
� CITY OF Fax: (408)777-3333
UPERTINO
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 w 1 comply with the above stated policy on re-roofing.
Homeowner's Name:
Job Site Address 22.3 / 1 �i84—
Roofing Company Name: iV Y a� a/Yi✓�/.c�
Applicant's Signa Date:yL �
tGreg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper