07060199 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'rGTflR
PERMIT NO.
BUILDING ADDRESS: ANSON GLORIA A 07060199
22442 WALNUT CL
PERMTT ISSUE DATE
OWNER'S NAME:
ANSON GLORIA A 6 22
SANITARY NO.. 7
CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB IAECH
3 3wz0 LICENSED CONTRACTOR'S DECLARATION Job Description
W— 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
?Z� withScclion70()0)ofDivision3ofthcBusincssandPrafcssiunsCode,andmyliccnscis RE—ROOF DUPLEX, TEAR OFF EXISITING ASPHALT
sly Lifull force ceneClassdcffect. Licit SHINGLES AND INSTALL NEW ASPHALT SHINGLES
License Class
`p Date
Contractor
ARCHITECTS DECLARATION
j a< I understand my plans shall be used as public records
)yU
u.y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law far the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<m ff which requires a permit to construct.alter,improve,demolish,or repair any structure
Q-401 prior it)its issuance.also requires the applicant for such permit to file a signed statement ,Ft.Floor Area Valuation
Z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $7000
il-- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). 3570303 -3 .
❑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.70M4,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
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.).
CalI,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sed.7044,Business and Professions Code:)The Contractor's Li-
cerise Law docs not apply to an owner of property who builds or improves,hereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner � �� `^�" Dare L 0
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I hsve and will maintain a Certificate of Consent to self-insure for workees compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I 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 Workees Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one 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 manrjcrr so Itcnto come subject to the Workers'Compensation
Laws of 1 for a.Date - a
ApplicantTla
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z, 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 A Lender's Name
az Lender's Address
U 0 1 certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
rJ 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
liabilities,judgments,costs and expenses which may in any way accrue against said City j
U Z in consequence of the granting of this permit. Date
►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b'�:
SOURCE REGULATIONS.
LIzzkl Re-roofs
91
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of:Zoof
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)? pfNo All roof: shall be inspected prior to any roofing material being installed.
❑Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes fgNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 75505.25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the Occupant of the Date
requireme�is which must be met prior to issuance of a Certificate of 0ccpancy. S lgnatul�of Applicant
1 L;l'10-4 All roof coverings to be Class"B"or better
Owner or authorized agent Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot:
APN 35703035 . 00
DATE ISSUED. . . . . . . : 06/22/2007
RECEIPT #. . . . . . . . . BSC00001754
REFERENCE ID # . . . : 07C60199
SITE ADDRESS 22942 WALNUT CL
SUBDIVISION
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ANSON GLORIA A
ADDRESS
CITY/STATE/ZIP CUPERTINO CA, 95014-2742
RECEIVED FROM DOTI ISAMU TOKUNAGA
CONTRACTOR LIC # *OWNER*
COMPANY ANSON GLORIA A
ADDRESS
CITY/STATE/ZIP CUPERTINO CA, 95014-2742
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY kMOUNTPD-TO-DT THIS REC NEW BAL
---------- - --------- ------
BPERMFEE VALUATION 7, 000 .00 137 .16 0 .00 137 .16 0 .00
BSEISMICRE VALUATION 7, 000 .00 0 . 70 0 .000_ ----70 -0 .00
- - -
TOTAL PERMIT
137 . 86 0 . 00 137 . 86 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- --------------------
CHECK 137 .86 772
---------------
TOTAL RECEIPT 137 .86
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-
-------- ----------------------------
------- ----------------------------
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
CITY OF CUPERTINO
E AC F
PE T NO PERMIT APPLICATION FORM
APN# Date:
Bui lingAddress:
a. ��{�2 WaC�w1- (?�rtl� SO�t►%� , Cu-- ► {,'� q57} Iy
Owner's Name: Phone#:
cc Av
Contractor: License#:
C ntact: Cupertino Business License #:
60S`4 3
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
p Asphalt Shingles )� Asphalt Shingles 40 r�J�
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings j ❑ Provide I.C.B.O.Report#
Q To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read,Understand and Will Comply With Cu ertino's Tear Off Policy: ❑k
Job Description: Vl We&- ye,
{ � . I�,6hL,,("C-• ,
p a '� . � ww. 40 ,� iil f< . 1 l"�✓.fib/la{�� 3`6 5��-+�`v�, f��f-cetT �,N f 2,
Residential Commercial ❑
Fire Zone: Yes ❑ No M Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupan` oup:
400o
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
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
f
6176/L4 A i_i Telephone: (408)777-3228
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 buildinp 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 f irst 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:
Job Site Address: a `-�3g `�`l�- 5. t•U a,J�tti�l Ci rcd .
Roofing Company Name:
Applicant's Signature: Date: Lb�D 0
Greg Casteel
Building Official
Revised 11/2/04
OWNER-BUILDF R VERIFICATION
1. (Check one) I or my immediate family I parent, spouse or child) will perform:
A. All the work authorized by this permit
B. — A portion of the work
C. — None of the work
If B or C is checked,c)mplete 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 a'3,ove is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: L Date:
'`i`–
Job Address: G(C-' so-L4Permit#
Any changes to the information provided ori this form shall be submitted to the City of Cupertino Build
Department.
Community Development
10300 Torre Avenue
. Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
'"WERTINO
B1, ildin De artment
JOB ADDRESS: PERMIT # �060� Y
�aq 3g �a-U 4 2 6
OWNER'S NAME: f a k r� ci c� ra ti PHONE# 0 zsk- 2�►��
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Sig nature Date
Please check applicable subcontractors and complete the followin 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
E--------
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Date
Owner/Contractor Signature