08100141 CITY OF CUPERTINO
BUILDING DIVISION PERMIT #C� PiT'RACTCTR�INIE'OI.tM.A,�ION
-£zw�,
BUILDINGADDRESS: PERMIT NO.
22071
OWNER'S NAME: PERMIT ISSUE DATE
HO A CONTROL NO.
1510) 351-1922
ARCHRECOENGINEER:
BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
0 0 0 0
fop LICENSED CONTRACTOR'S DECLARATION IDM Description
U I hereby affirm Nal 1 Am licensed under provisions of Cbe)zr 9(commencing
moo don7fl(IB)of DiAAon3ofthe Busin=va feuiou Com.andmy nccnhuia
a y mfolfan:eande OIL E—RF TO CMP 1 ROLLD RF REAR PATIO APPLY 7/16"OSB
i Lkenhu CI LIc.I
Dam Contrrar & CLS A CMP 19SQ
e pp A H CTS DECLAR ON
e C 1 understand my plans Mall be used As public records
Dyu
�4.ts, U.Mcd Professuned
v�
3 OWNER-BUILDER DECLARATION
ur
i E I hereby affirm that 1 am exempt from the Conla ctm's License Law for Ne
00 fallowing mown.(Section 7071.5,Business and Professions Cale:Any city or county
$ which roque.A permit so mnswct,alar.improve.mmnlW,ar repair my a memre
i y prior to its issuance.also m n ices the applicant for such permit m file a signed suamenl
pp Nat he is licensed purshand 10 tho provisions of the Coneactues License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section70D0)of Division 3 of the Business and Profasdons Code)or
—
that he is exempt therefore,and Ne basis for the ailcgcd Assumption.Any violation of 89225
Section 70315 by asry applicant fara permit subjects the applicul m A civil penalty of APN Number Occupancy Type
not mart than few hundred rollers(SSW).
❑I,uowzro[thepropmy,armywplayceswithwagasstheirsokcampensstion, 32602019 . 00
And mdse Hark,and Inc he Comunots Lnmde anem0farsok(Sm.In ax,Buse••of
prod erns wh bis Cale:The ms tucton.n.and
who law ren Out aims ff rt Doris is Required Inspections
Arm enrwW��ad,aimpet men
mrove who doesAmuch
in wdedaraelrorNestle his
howemplayms,provided thataovemimpsotemmu are not intended moBered fm owner.
however.the have
use,
ar improvement is hush within one year ar completion,the awnsr-
Wilmr ,will naw Ne buNm of proving that he did ren build m improv far purpose of
uk.)
❑1,u owner of the Property,Am exclusively contracting Aids licensed eonahutom In
mnstroct the project(Sec 7010,Business and professions Cade:)The Cmtsacmfs Li-
cesse taw does not apply man owner of property who builds or knproves 0termn.and.
A W contracts far such praj ets with aemwcumW livered purseanl m the Cmtrutofs
LCCILY Law.
❑I Am exempt under Sm ,B d:P C for this mason
Owner Dam
WORKERS COMPENSATION DECLARATION
I thereby Affirm under penally of perjury one of the following mcluatione
I ham and will maintain aCer6fcam of Consent to self-imum Tar WoftesCompen-
'on,a provided far by Section 37W of the Laem Code.Tar the Note..or the
wart fo hub this permit is issued.
haw And will maintain WorkzeA Compensation Insurance,u myvimd by Section
o(Ne lather Com,for to pcdormaze of the,work far which Nu parmh is issued
My Wos Campewbtrvan lyse rags icy alleyNo �3�
Came TOFE ((�a
CERTIFICATECOOF EXEMPTION FROM WORKER
COMPENSATION INSURANCE
(Thu seNm zea rct be canpleed Ir Ne pewit V far oz nunthed mean(s1 W7
nr les,)
1 ceniry that in the performance of the work for which this permit is issued.1 shall not
employ any scrmn in Any muzrm As an Become subject to rte Worker'Compcnsanm
I.of CAlifomia Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenificaa of Exemption,you should
become subject An the Woftei Compcnsstion provisions of On,Lobar Cade-you most
.,Z forthwith comply with such previsions m this permit NAIL be deemed mated.
Zi 0
CONSPRUCr10N LENDING AGENCY
[-�51 I hereby allum NU Vert lsp conhuu d.leading agency far the performance of
[Yi
doe worse far which this permit Is issued(Sec.3097,Civ.C.)
W�Q Lcndefs Num
z Undoes Address
V 0 1 sexily that I have read this application and state Nu the aWve infeemau^n u
ty F cornea.I Agree m empty with all city and manly on iwscn and stale laws mkdng be
.� building construction,said hereby authorire rtpmsmutives of this city to mar upon Ne
[r7 show-mentiuzd property far inspection purposes
(WA)agree to save.indcmnify and less the
i y liabilities,judgments.costs and eapeaws whiicch m�manyy waCity
Intense against said Cat
C)Z
in CGroxxxnamoC APPLICANT of ODE STANDS daC treating A WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURCE LATI NS.
Re-roofs
Signal reaf ApplicuVCcar Dam
11 DOUS MATERIALS DISCLOS RE Type of Roof
Will the applicant or future building mmpztstore or bandlc haurmu material
As mfizd by the Cupertino Municipal Com.Chapter 9.13.and the HALM and Safety -
cade,seeaas 15572(a)7
❑Yn All roofs shall be inspected prior to any roofing material being installed.
Will Nc applicant ar future Wilding occu,ml use equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
it huaNnus air mntsmirrnes As defined by Nc Bay Arta Air Quality MAnagement all new materials for inspection.
C
Ya
❑ ON
Ihawe,ad the aerialM533t mmtsunder Clepadthsaifthe Calif.,.lig
near z:f akryCale, 25305,25377 vnd25570.1 undcrststW Nuif Nc building �-
does zt corm tiY waren L Utas it u my respansildlity m ratify tie aces ant of the f
reyuimmen he, x br Arca ala cenifieeaar gltlpm Signature of Applicant Nate
Ow reran omcd erg t / Dam',
All roof coverings to be Class's?"or better
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32602019 . 00
DATE ISSUED. . . . . . . : 10/22/2008
RECEIPT #. . . . . . . . . : BS000006437
REFERENCE ID # . . . : 08100141
SITE ADDRESS . . . . . : 22071 HIBISCUS DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER HOOPES RICHARD N AND PAMELA J
ADDRESS . . . . . . . . . . : 22071 HIBISCUS DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95,014-0108
RECEIVED FROM . . : KATHERINE A RIDOUT
CONTRACTOR . . . . . . . : KATHY RIDOUT LIC # 24669
COMPANY . . . . . . . . . . : RIDOUT ROOFING CO INC
ADDRESS 621 WILLIAMS STREET
CITY/STATE/ZIP . . . : SAN LEANDRO, CA 94583
TELEPHONE . . . . . . . . : (510) 351-1922
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- --- ------- --
1BSEISMICR VALUATION 9, 225 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BUSLIC FLAT RATE 1 . 00 110 . 00 0 . 00 110 . 00 0 . 00
1REROOFRES SQ FEET 19 . 00 247 . 00 0 . 00 247 . 00 0 . 00
---------- ---- --- ----------
TOTAL PERMIT 358 . 00 0 . 00 358 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------------- ------ ----
CREDIT CARD 358. 00 VISA
---------------
TOTAL RECEIPT 358. 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------------- -------- ----- ------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
O
02100
�a, .
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION
APN #
Building Address: _
of O —1 1 tr ��
Owner's Name: Phone #:
Pa Vv% eko,, D o (f 0S/--? 3 -a( �3
Contractor: (� / (>L_ I LA I,r 0. , Phone #: S lD 35' \ —1 q Z
Rl a G� "►,-0 �i- l_ t�c. .,�v- o Fax#: Sl O 5'j—1 — LV_7 573
Cupertino Business License'#'. 'V( 7 Contractor License #:
040 C `39
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) Ot i ify
Number of existing coverings � rovide I.C.B.O. Report #
To be Removed ❑ Provide Mfgr. Installation Specs.
i a� C
Job escpption:n p
Residenti Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation: TZ 2, u�
I Have Re d, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 6/16/08
CITY OF CUPERTINO
t REROOF
CUPEr,T1NO FEE SCHEDULE '
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1RER00FC0M Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
IREROOFRES Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roof Multi-Family B 1MFDWLROOF
IBSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08