07050037 777777.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDIr;G�n�gEsGASCOIGNE DR JOHN HENRY ROOFING 07050037
US !M U PERMIT ISSUE DATE
OWNER'S NAME:
MONTROSE, ROGER 12780 CLAYTON RD 05/07/2007
SANITARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHrrEcriENGMER: TEAR O' F EX SING TAR AND
BLDG ELECT PLUMB MECH
I p p LICENSED CONTRACTOR'S DECLARATION Job escription
V
p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
.Zin with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and eIfe�l c
License C�S= Lam•g /
3 Date — Z Contractor Abe
gg ARCHITECTS DECLAIDITION
1 understand my plans shall be used as public records
)WU
U.12 Licensed Professional
O 2 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
OO 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
u Z y prior to its issuance,also requites the applicant for such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft. Floor Area
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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).
❑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 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.).
❑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.
❑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:
Wr I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
s3tion,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 Workefs Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workeees�C/o'mpensation Insurance car. and Policy number are:
Carrier._5 /�r C e IKI Policy Ne I �9 X0^ 10s�
CERTIFICATE OF ExEmFnoN FR WOR E s' o
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.1 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 Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
z OCONSTRUCTION LENDING AGENCY
[~i CA I hereby affirm that there is a construction lending agency for the performance of -
(1!> the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
0, Lender's Address
U O 1 certify that 1 have read this application and state that the above information is
U. r r correct.I agree to comply with all city and county ordinances and state laws relating to
0Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments•costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
►' APPLICA%11DERSTANDS AND ILL C MPLY WITH ALL NON-POINT Issued by:
SOUATIONS.
16 M7-e Re-roofs
Signature ofAppIj&vXContra&r Date Type of Roof
LAJAZARDOUS MATERIALS DISCLOSURE
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)? All roofs:;hall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
If a roof i:.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 m 3terials for inspection.
District?
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently ha a tenant,that it is my ponsihility to notify the occupant of the
requireme hcmetp or i era fi teofOcupp�� Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized age Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 37523009. 00
DATE ISSUED. . . . . . . : 05/07/2007
RECEIPT #. . . . . . . . . BS000001218
REFERENCE ID # . . . : 07050037
SITE ADDRESS . . . . . : 10540 GASCOIGNE DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER MONTROSE, ROGER
ADDRESS 10540 GASCOIGNE DR
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM RECEIPT INTERFACE
CONTRACTOR JEROD M OLEKI LIC # 25872
COMPANY JOHN HENRY ROOFING
ADDRESS 12780 CLAYTON RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95127
TELEPHONE (408) 241-1334
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- --=------- ----------
BPERMFEE VALUATION 5, 000 .00 115.56 0.00 115 . 56 0. 00
BSEISMICRE VALUATION 5, 000 .00 0.50 0 .00 0 .50 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 116 . 06 0 . 00 116 . 06 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 116 . 06 1713
---------------
TOTAL RECEIPT 116. 06
CITY OF (-1UPERTINO
az�,_ REIZOOF
CITY Of
CUPERTINO PERMIT APPLICATION FORM co V
APN# _3 l 5_ — .23 'DO / ate:
Building Address: GI<5�01 rt�
G .J -
Owner's e: Phone#:
Contrac r: e. t� � I L o��1 License#:
Contact: G Cupertino Business License #:
D /0 G b
Type of Roof Covering:
ExiPropos
TBuilt-Up Roof e Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles c
Ll Other(Specify) D ❑ Other(Specify)
Number of existing coverings 1i ❑ Provide I.C.B.O.Report#
eQ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read,Understand and Will Comply With Cupertino's Tear Off Policy:
Job Descriptiop:
r
. ._6- V_W a
Residential t Commercial ❑ D
Fire Zone: Yes 1 No ❑ Confirmed with Planning De t. if
there are any restrictions:
Cost of Project: Type of Construction: Oecupancy group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Icldg 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
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 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 apprcval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed,a plywood nail:nspection is required.
6. Any roofing which is applied without f:.rst obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be perfcrmed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee .)f$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: ` /,, S
Job Site Address: Z 6d
Roofing Company Name: �I 1y y
rany
n
Applicant's Signature: Date:
Greg Casteel
Building Official
Revise,111/2/04
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
-UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
O R'S NAME: o A, PHONE #
GENERAL CONTRACTO : 0 #
r
I am not using any subcontractors: ` 5 —7 — d
, ature Date
Please check applicable subcontractors and cmom lete the following 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
Plumbing
Roofing �> 2 Rio � 7 2-
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Signature Date