09010075 CITY OF CUPERTINO
BUILDING DIVISION PERMITL1' TRI +1? Ll r
BUILDING ADDRESS: PERMIT NO.
22284 PALM AVE LOS G TOS R
OWNER'S NAME: PERMIT ISSUE DATE
1N S A CONTROL NO.
(408) 298-9399
ABUILDING PERMIT INFO
RCHITECr/ENGINEER:
BLDG ELECT PLUMB MECH
a 0 o a
u0C LICENSED CONTRACTOR'S DECLARATION Job Description
U 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
y in full fora and effect. RE-RF RMV EXTNG SHKRF (.MN HSE ONLY) , INS`�'L
'�= �""'a`c' Le.x 77/160SB&RFRS SELCT FLT, PRES TL SHNGLS BY
r Date Contractor
ARCHITECTS DECLARATION
Fos< 1 understand my plans shall be used as public records C ERTA I NT E ED CLS A 2 7 S Q
�yU
4 G H Licensed Professional
rn OWNER-BUILDER DECLARATION
�y! I hereby affirm that 1 am exempt from the Contractors License Law for the
i p o following mason.(Section 7031.5,Business and Professions Code:Any city or county
I
Pi 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
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
ns
Y,
F=-$ (commencing with Section 7000)of Division 3 of to Business and Professions Code)or $8900
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 APN Number Occupancy Type
not more than five hundred dollars(M). 35704032 . 00
❑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 (1 p
property who builds or improves thereon,and who does such work himself or through his
owe 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 Contractors 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 Contractors
License law.
❑I 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 have and will maintain a Certificate of Consent to self-insum for Workers Compen-
salon,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 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 Work��omon lnwrrana cagier and Policy number am:
Grrier s se / PoI'hry No.; q R Z!7 tJ 8
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
1 cenify 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 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z"4 CONSTRUCTION LENDING AGENCY
(~i rr,n-i I hemby affirm that there is a construction lending agency for the performance of
LY+> the work for which this permit is issued(Sec.3097,Civ.C.)
W 0 Lenders Name
az Lenders Address
U 0 1 certify that I have read this application and stale that the above information is
LL" comm I agree to comply with all city and county ordinances and state laws misting to
6 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentoned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
p.4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE EGULATIO
YJ ea %v 9 Re-roofs
Sign rcfo Applicant/Contractor 'Date
Type of Roof
HAZARDOUS 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 shall be inspected prior to any roofing mate
firial being installed.
C]Yes 34No
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
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes %No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the building f
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirement h must be mqfpiior to issuance of a Certificate of Occupancy. S 1 ature of Applicant Dafe
r
e)9 All roof coverings to be Class". 'or better
Owncr authorizcd agent tae
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35704032 . 00
DATE ISSUED. . . . . . . : 01/16/2009
RECEIPT #. . . . . . . . . . BS000006988
REFERENCE ID # . . . : 09010075
SITE ADDRESS . . . . . : 22284 PALM AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER LILY WATANABE
ADDRESS 22284 PALM AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2709
RECEIVED FROM . . . . : LOS GATOS ROOFING
CONTRACTOR RANDY BROWN LIC # 23481
COMPANY LOS GATOS ROOFING
ADDRESS P 0 BOX 1726
CITY/STATE/ZIP . . . : LOS GATOS, CA 95031
TELEPHONE . . . . . . . . : (408) 298-9399
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 8, 900 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 8, 900 . 00 0 . 90 0 . 00 0 . 90 0 . 00
1REROOFRES SQ FEET 27 . 00 351 . 00 0 . 00 351 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 352 . 90 0 . 00 352 . 90 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 352 . 90 #2748
---------------
TOTAL RECEIPT 352 . 90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
0 X75
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION
APN # Date:
3S -7 -6q- 623Z 0 ZI /y o5;
Building Address:
2-2-2 Yz/ 1111,,-2 Xt .
Owner's Name: Phone #:
Contractor: Phone #:
Fax #: /
Cupertino Business License #: Contractor License #:
do
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) �9, Other(Specify) 16''7 �e. f
Number of existing coverings ❑ Provide I.C.B.O. eport#
To be Removed /1� Provide Mfgr. Installation Specs.
15 Is
Job Des ption:
706 ,056
cX-r c
Residential Commercial ❑
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation: plq
a O ----
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signaft re
Revised 6/16/08
CITY OF CUPERTINO
REROOF
CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1RER00FRES ' Re-roof Residential B 1SFDWLROOF
1BSEISMICRE Seismic Residential B
1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1 BUSLIC Business License B
Revised 6/16/08
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 2007 IBC Standards
and manufacturers specifications on re-roofing.All roofs are Class "A"per Cupertino
municipal code 16.04.080.
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.
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: Azv
Job Site Address:
0
Roofing Company Name:
Applicant's Signature: D
Greg Casteel
Building Official
Revised 07/30/08
I.Windows
1.Install Energy-Efficient Windows
a.Double-Paned 1 Energy pt y=yes 0
b.Low-Emissivity(Low-E) 2 Energypts y=yes 0
c.Low.Conductivity Frames 2 Energy pts y=yes 0
2.Install Low Heat Transmission Glazing 1 Energy pt y=yes 0
1 1 1
J.Heating Ventilation and Air Conditioning
1.Use Duct Mastic on All Duct Joints 2 Energy pts y=yes 0
2.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health pt y=yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy pt y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
6.Install Sealed Combustion Units
a.Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEER/11 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoves/inserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15.Install High Efficiency Filter 4 IAQ/Health pts y=yes 0
16,Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pts y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y=yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy pts y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts y=yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) Up to 18 Energy pts 0
6.Select Safe and Durable Roofing Materials 1 Resource pt y=yes 0
7.Install Radiant Barrier 3 Energy pts y=yes 0
1 1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts . y=yes 0
3,Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes 0
1 1 1
Community Development
: 10300 Torre Avenue
' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
,,UPEI,TINO
Building Department y
JOB ADDRESS: PERMIT
OWNER'S NAME: ��/_ �/� PHONE % ,��J �f
GENERAL CONTRACTOR: '
I am not using any subcontractors: 9
Signature `D 'e -+
Please check applicable subcontractors and complete the following information:
SUBCONTRAC T OR BUSINESS NAME I BUSINESS LICENSE
Cabinets &Millwork
Cement Finishing
Electrical
Excavafion
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heat ng
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank-
Sheet
ankSheet Metal
-.Sheet Rock
Tile
Owner/ Lor Signature Dat