07030096CITY OF CUPERTINO
+C�1g:tTtiR IIQIYZMTI�iN• '
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
11902 SHASTA SPRING CT
LOS GATOS ROOFING
07030096
PERMIT ISSUE DATE
OWNER'S NAME:
HAILER IRMGARD E ET AL
888 F L T
SANITARY NO. CONTROL NO.
:)NE:
BUILDING PERMIT INFO
ARCHTTECT/ENGINEER:
REMOVE EXISTING SHAKE TOOF,
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I7PZ Ju Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. and my license is
in full L O
I LieN J
LDiactec C�andC •
ute
i Contractor
{ ARCHITECTS DECLARATION
! I understand my plans shall be used as public records
i
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
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
prior to its issuance, also requires the applicant for such permit to file a signed statement
9
Sq. Ft. Floor Area Valuation
cthat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
APN Number Occupancy Type
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages az their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law docs net 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 -
did build or improve for purpose of
builder will have the burden of proving that he not
sale.).
❑ 1, 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-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ J am exempt under Sec. B & P C for this reason
-
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm: under penalty of perjury one of the following declarations:
1] 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.
❑ 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 Wo C kpeopfien Insurale carrier and Policy number 2�are:
I
J ✓N Policy No.: I L--
Carrier... 11
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed 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, l shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Coda, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
►�-. 1 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.)
A Lender's Name
Z Lender's Address
I certify that I have read this application and state that the above information is
O correct. I agree to comply with all city and county ordinances and state laws relating to
U building conswction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments, costs and expenses which may in any way accrue against said City ry
in of th ranting of this permit. Date 3-
Z consequence
APPLICANT Prattling
AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOURCE NS.�,�
Re -roofs
Signature of Applicant/Contractor a"
HAZARDOUS MATERIALS DISCLOSURE
Type c f Roof
yP
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
All ro-As shall be inspected prior to any roofing material being installed.
Code, Section 25532(a)?
Yes No
❑
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
'mit hazardous air contaminants az defined by the Bay Area Air Quality Management all new materia for inspection.
District?
Yes �No
1 have read the hazardous materials requirements under Chaptcr 6.95 of the Califor• /
SafetySections 25505, 25533 and 25534.1 understated that if the building l
nia Health &Safety ode,
does not currently ve a tenant, that it is my responsibility to notify the occupant of the
rcquircmcn t be mel prior to issuance of a Certificate of Oc ancy. Signal ure of Applicant Date
All roof coverings to be Class "B" or better
Owner or au orixcd agent Date
2 ITEMS OF 2
CITY O? CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: BLk: Lot:
APN ........: 35655025.00
DATE ISSUED.......: 03/13/2007
RECEIPT #......... B3000000681
REFERENCE ID # ...: 07030096
SITE ADDRESS .....: 11902 SHASTA SPRING CT
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: bethe
COPY # : 1
OWNER ............: HALLER IRMGARD E ET AL
ADDRESS ...........
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5107
RECEIVED FROM ....: RECEIPT INTERFACE
CONTRACTOR .......: RANDY BROWN LIC # 23481
COMPANY ..........: LOS GATOS ROOFING
ADDRESS ..........: 888 FAULSTICH CT
CITY/STATE/ZIP ...: EAN JOSE, CA 95112
TELEPHONE (408)298-9399
FEE ID UNIT
QUANTITY
AMOUNT
PD -TO -DT
----------
THIS REC
--
NEW BAL
-----------------------
BPERMFEE VALUATION
----------
9,984.00
----------
169.56
0.00
169.56
0.00
BSEISMICRE VALUATION
9,984.00
1.00
0.00
----------
1.00
----------
0.00
----------
TOTAL PERMIT
----------
170.56
0.00
170.56
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE NUMBER
--------------------
----------------- ---------------
CHECK
170.56
1865
---------------
TOTAL RECEIPT
170.560
CITY OF1
CUPEkTINO
CITY OF CUPERTINO
REROOF
PERMIT 1.PPLICATION FORM
07 0 3ooq�,
APN # .,
Bldg Permit Fees
Date:
BENERGY
Energy
BUILDING
Building Address: JJ
1902O11902-
BSEISMICOM
Owner's
wner's Name:'44
BUILDING
Phone #: ,
Plan Check Fee
BUILDING
BUSLIC
Contractor: PJ lone #:
-a Ji)
40
License #:
�0O�07�-
Contact:r)
PY one #:
�
Cupertino Business L n e #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
❑ Asphalt Shingles
X Wood Shakes
71 Wood Shakes " 13 "
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
'�l Other (Specify),4STM 30 �-,_1f
Number of existing coverings 1
EI Provide LC.B.O. Report #
To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu
ertino's Tear Off Policy:
Job Description:y�
- tj
Residential Commercial ❑
Fire Zone: Yes ❑ NoZ
Confirmed with Planning Deft. if.
there are any restrictions: LLJJ
Cost of Project: Type o onstructi
��
n: Occupancy group:
o L
Qty. if
Applicable
Fee ID
Fee Description
FPe (-Trniin
BPERMFEE
Bldg Permit Fees
BUILDING
BENERGY
Energy
BUILDING
_ SEISNiLCE_t--.--
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) 777-3228
CITY OF Fax: (408) 777-3333
CUPEl�TlNO
Building Department
Subject Re -roofing policy for the City of Cupertino
1. Prior to permit issuance, you mu st agree to comply with 1997 UBC Standards
and manufacturers specification: on re -roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the b-i.ilding-4nspector. A final inspection and
approval shall be obtained from :he 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 fl e City, the following steps are
required:
1) Pre -inspection and/or tear oft approval.
2) In -progress inspection approc al.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywoo3 nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all ne ;v material down to the sheathing,
so a proper City inspection can b? 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 will comply with the ,above stated policyon re -roofing.
Homeowner's Name:
.- _-__ -ohSite-A.dd -ess:_
Roofing Company Name:
� 0
Applicant's Signature: A:5zlo�
Greg- feel
Building Official
Revised 1/30/03
Pi inted on Recycled Paper
Date:
CflY OF
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Buildin Department
JOB ADDRESS:// c7O 2 _ ? Cf S GI rih c,
PERMIT #
OWNER'S NAME:
PHONE # C ',2_U -Z. 3
GENERAL CONTRACTOR��,-5 &z�fo5
FAX #
M
I am not using any subcontractors:
Signature
Please check a livable subcontractors and cc m lete the following information:
Date
Owner/ Contractor Signature
Date
60
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
Owner/ Contractor Signature
Date