06100117 CITY OF CL ERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: ELLI0TT ROOFING PERMIT NO. 06100117
11165 L PERMIT ISSUE DATE
OWNER'S NAME: in i6 /?nn6
STILLMAN BEN AND GEORGIANNk TR72 SANITARY NO. CONTROL NO.
.ONE:
(831) 423-0675 BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
UU with Section 7000)of Division 3 of the Business and Professions Code,and my license is
Z LU
o y in full force and cfj ct TEAR OFF SHANKES, INSTALL OSB, INSTALL NEW COMP
License Class CLASS A
p Datc Contractor
F CHITECPS DECLA ON
C< I understand my plans shall be used as public records
hyU
u. Licensed Professional
i 0'< OWNER-BUILDER DECLARATION
3<2 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Profacvions Code:Any city or county
which requires a permit to construct,alter,improva.demolish,or repair any structure
fin prior to its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area Valua�q[il 4 81
?< that li is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
F=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
s .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(x500). 35616038 . 00
❑1,as owner of the property,or my employees with wages as their sale compensation,
will do the work,and the structure is not intended or offered for We(Sec.7044,Business Required Inspections
and Prufessions 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.).
Q I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Set.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
1 hereby affirm under penalty of perjury one of the following declarations:
Q 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 WZ409;
r and Policy number arc:
CarriePolicy No..TION FROM WORKERS' S9 fir
COMPENSATION INSURANCE�� /✓r J
(This section need not be completed if the permit is for ane hu dollars($100)
or Icss.)
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.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 R CONSTRUCTION LENDING AGENCY
E.r...r I hereby affirm that there is a construction lending agency for the performance of
Q!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
I certify that I have read this application and state that the above information is
V. correct.I agree to comply with all city and county ordinances and state laws relating to
CUbuilding construction.and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep hamrlcss the City of Cupertino against
0 cA liabilities,judgments•costs and expenses which m}y y way accme against said City
V Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND W.IL OMPLY 11 LL N P NT Issued by:
SOURCE G�LATIONS.�
Re-roofs
Signature of ApplicanU mtracto °are T Of Roof
HAZAR S MATERIALS DISCLOSURE Type
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 shall be inspected prior to any roofing material being installed.
❑Yes _11�No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �Nu
I have read the hazardous`materials requirements under Chapter 6.95 of the Califor-
nia Health&SaOv Code,Sections 25505.25533 and 25534.1 understand that if the building
does not cyprifahave a at it is y ponsibility to notify the occupant of the
requi n hick prior u once of a Certificate occ pancy. Signature of Applicant Date
` < All roof coverings to be Class"B"or better
O `cr or authorized agent Datc
CITY OF CUPERTINO
.em 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35616038 . 00
DATE ISSUED. . . . .. . : 10/16/2006
RECEIPT # . . . . . . . . . : 36452
REFERENCE ID # . . . : 06100117
SITE ADDRESS . . . . . : 11165 LA PALOMA DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER STILLMAN BEN AND GEORGIANNA TR
ADDRESS
CITY/STATE/ZIP CUPERTINO CA, CA 95014-4772
RECEIVED FROM JIM ELLIOTT
CONTRACTOR . . . . . . . : JIM ELLIOTT LIC # 25914
COMPANY . . . . . . . . . . : ELLIOTT ROOFING
ADDRESS . . . . . . . . . . : 723 ALMAR AVE.
CITY/STATE/ZIP . . . : SANTA CRUZ, CA 95060
TELEPHONE . . . . . . . . : (831) 423-0675
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- ------
BPERMFEE VALUATION 12 , 000 . 00 191 . 16 0 . 00 191 . 16 0 . 00
BSEISMICRE VALUATION 12 , 000 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 ------0_00
---- ------ ---------- ----------
TOTAL PERMIT 297 . 36 0 . 00 297 . 36 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
-- - - ---- -- --- - --- -- -- -- ------ ---------------
CHECK 297. 36 9319
TOTAL RECEIPT 297 . 36
Community Development
10300 Torre Avenue
Co Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT
�-- o
\\CAS �..�, ,)L�-,<1 G
OWNER'S NAME: a 11 rr,G, PHONE # $lk
GENERAL CONTRACTOR: E 11 l o44- FAX # C�31 �.t3—OCo$Co
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork .0 s" /9"!
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
T)le
Owner/Contractor Signature Date
Community Development Department
Building Division
Ilk, City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPEI�TINO
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 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 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 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: -6an S--- I` fns
Job Site Address:
Roofing Company Name: \ �o
A plicant's Signature: Date: jCo6
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
alF
CITY OF CUPERTINO 0Cq 1 coo I I-+
iREROOF
CUPRINO PERMIT APPLICATION FORM
j
APN# ? �} �_, 1(O J O 35 Date: �p&okxp
Building Address:
Owner's Name: Phone#:
Contractor: Phone#: License #:
E)i►4A- C�3�� `�23-C 7� Li1 `-1
Contac Phone#: . Cupertino Business License #:
or- ,?q A
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings_ V _ ❑ Provide I.C.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: i e -oz
oz-(-,
Residential % Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning DrTt. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
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