07060247 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: -- PERMIT NO.
22680 ALCALDE RD GARY COLBETT CONSTRUCTION 07060247
OWNER'S NAME: PERMIT ISSUE DATE
KSAR MICHAEL Y AND RENEE x ,/2712007
iE: SAM�1ARY NO. CONTROL NO.
(831) 420-1148
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1088 LICENSED CONTRACTOR'S DECLARATION Job Description
V I= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;zw in full ndefefDivision3oftreBusinessandProfessionsCode,andmylieerc9eis RES. 2 I3ATH REMODELS NON STRUCTURAL INCLUDING
a ti in full force and effect A �] i( '3 r
z License Clads Lic.it ^C l"4' LIGHTING 54 S EA.
w Date !_ f Z Contrauor qQ, GQ(�t�CIT z 4
J AR HITECr'S DECLARATI N
a< I understand my plans shall be used as public records
>yU
y Licensed Professional
}
OWNER-BUILDER DECLARATION
j t 1 hereby affirm that 1 am exempt from the Contractor's License law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior to its issuance.also requires the applicant for such permit to file a signed statement
_a that he is licensed pursuant to the provisions of the Contractor's License Law(chapter 9 ;iq.Ft. Floor Area Valuation
f- (commencing with Section 7000)of Division 3 or the Business and Professions Code)or $12000
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of c�}{D{��r Number Occupancy Type
not more than five hundred dollars($500). 34244019
V V
Q I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered ror ale ff.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
Q 1,as owner of the property,am exclusively contracting with licensed amnaetors to
construct the project(Sec.7044,Business and Professions Code:)The Comuactoes Li-
cense Law does not apply to an owner of property who builds or improves thoean,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
Q I am exempt under Sec, B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
t_I I have and will maintain a Certificate of Consent to self-insure for WedwesCampen.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Workers Compensation Insurance carrier and Policy number are:
Carrier /L{at- J 10 3th Policy No.i<ZQ 00 2)7gS6'2-7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars(5100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California Dates
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Worker's Compensation provisions of the labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed rcvokrA
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a concoction lending agency for the performance of
rZ r' the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
a2 Lcndees Address
U Q I certify that I have read this application and state that the above information is
C14 correct-I agree to comply with all city and county ordinances and state laws relating to
!� U building construction,and hereby authorise representatives of this city to enter upon the
1-L1 above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
"Hy fn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date e, Z
SOURCE R ONS. _
-- �� 4 'AN(0y Re-roofs Q
Sign Pure of Appliant/Contractor Due:
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
Q Yes No
All roofs shall be inspected prior to any roofing material being installed.
�Q
Will the applicant or future building occupant rase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
District?
QYes NO
I have'cad the hazardous materials requirements under Chapter6.95of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand"if the building
does not currc have a tenant,that it is my responsibility to notify the occupamt of the
requircir wh; mu mar a of a certificate or Signature of Applicant Date
C."A a') All roof coverings to be Class"B" or better
Owner or authorized agent Daic`
CITY OF CUPERTINO
'
BOLDING DIVISION PERMIT
UI ' ±C�'_.'. ` ".:�T±b�.I �:}}I.t1VI:�Z'If.1►:N..�::::.
41 �c3`Z ALDERBROOK LA LOS
BURL PERMIT NO.
ES
T(�S ROOFING 107060183
OWNER'S NAME: PERMIT ISSUE DATE
1 DICKSON TERRENCE E ET AL P 0 BOX 1726 106/21/2007
JNE: (408) 293-9399 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 a
Op LICENSED CONTRACTOR'S DECLARATION
V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing lob Description
z, with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is REMOVE 2 LAYERS OF EXISTING ROOFING. INSTALL
°- in full force and effec
z LicenseCl Lic.x 00:f 0 7/16" 0 3B AND ROOFERS SELECT FELT. INSTALL
,FC Date Contractor
ARCHITE fltar��is`r� PRESIDENTIAL TL SHINGLES.
CTS DECLARA 1 N
w U 1 understand my plans shall be used as public records
,a _
W y Licensed Professional
y 1 OWNER-BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Contractors License Law for the
L O o following reason-(Section 703 1.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
EEO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation
r t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $7 2 2 5
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects The applicant to a civil penalty of a�pJ Number Occupancy Type
not more than rive hundred dollars(5500). 3692004 6:t�CJ' P Y yP
Q 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
Q I,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
tense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(Q licensed pursuant to the Contractor's
License Law.
Q I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued,
My Worker's ompensation Ins u carrier and Policy number am:+/ }
Cartier: J r(A� " Policy No.1Z0�"f q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compieted if the permit is foronc hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Da-
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(?!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
aZ Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
(y 0- correct.I agree to comply with all city and county ordinances and state laws relating to
C U building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
f4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by Date
SOUR EGULATION . _Q
Re-roofs
Signatu of Applicant/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant store or handle hazardous material
as dcrtncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Uv No
Will the applicant or future building occupant use equipment or devices which If a roof i s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
District?
Q Yes du
I have read the hazardous materials requirements under Chaptcr6.95 orthe Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requr is which mug be et prior i�j of a certificate of ccupancyyl Signature of Applicant Date
r x 0 All roof coverings to be Class"B"or better
ownc r authorized agent date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36920046.00
DATE ISSUED. . . . . . . : 06/21/2007
RECEIPT #. . . . . . . . . . BS000001734
REFERENCE ID # . . . : 07060183
SITE ADDRESS . . . . . : 10732 ALDERBROOKLA
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DICKSON TERRENCE E ET AL
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4604
RECEIVED FROM . . . . : LO: GATOS ROOFING
CONTRACTOR . . . . . . . : RAYDY BROWN LIC # 23481
COMPANY . . . . . . . . . . : LO:' GATOS ROOFING
ADDRESS P C, BOX 1726
CITY/STATE/ZIP . . . : LOS GATOS, CA 95031
TELEPHONE . . . . . . . . : (4(,8) 298-9399
FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
BPERMFEE VALUATION 7,225. 00 147 .96 0. 00 147 .96 0. 00
BSEISMICRE VALUATION 7, 225. 00 0. 80 0. 00 0.80 0. 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 148.76 0. 00 148.76 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 148.76 #1916
---------------
TOTAL RECEIPT 148.76
070 G 0 4-3
CITY OF CUPERTINO
REROOF
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: I
10-7 3� /¢Idp-r bror k Ln
Owner's Name: Phone
#:
rry � i�k��n 4vK 25 2--vs6 -7
Contractor: z Phony;#. O�j' License#:
r�f� s � q 93 9 9 �OOY07
Contact: Q LJ Phone #: � Cupertino Business License#:
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) IK Other(Specify) L G 8
Number of existing coverings `� ❑ Provide I.C.B.O.Report#
To be Removed ❑ Provide Mfgr.Installation Specs. 5 �8
I Have Read, Understand and Will Comply With Cupertino's Tear Off Policy:
Job esc ption: mL m ,AcTl-t-�,-q
Residential' 0 Commercial [] d
l
Fire Zone: Yes ❑ NOX Confirmed with Planning Deft. if.
there are any restrictions: LLff
Cost of Pr oje t: Type o Cons:ructi Occupancy group: ,I-- .,� - � r r'iio , tin k
a� 5 � Cam,
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY I Energy BUILDING
_------------ - - -,-_ ---BSEI$MICRE =BUILD-ING- -
BSEISMICOM + Seismic Commercial + BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3928
CITY OF Fax: (408)777-3333
CUPEro.—I
Buildin g Department
Subject: Re-roofing policy for tha 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 apFlied without first obtaining all inspection
and written approval from the build in&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 ;my 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 withoiit 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 cn the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name:
.-: —_ Jbb-Site_Address:_. X11-312
-- �- z 'r�•�...a_.. - - - - -- --- --
- - -
Roofing Company Name:
O
Applicant's Signature: Date: / ' il)7
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO _
Building Department
JOB ADDRESS: /Q�3 PERMIT #
076Ga J 7
OWNER'S NAME: -r'rr L ks a n I PHONE # y,,� ?.
GENERAL CONTRACTOR 71�st k �I I FAX#I am not using any subcontractors: j h—l�-t-tad 12-l
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
( Excavation
I I Fencing
Flooring: Carpeting
Linoleum/ Wood I
Glass/ Glazing
Heating
II Insulation
I I Landscaping I
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock I
Tile
N
4- �"j �/Z-, 0 :2
O er/Contractor Signature Date