09070003 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � � Z� MI
BUILDING ADDRESS: PERMIT NO.
10546 CYPRESS DR TBD - TO BE DJETZEMINED- 09070003
OWNER'S NAME: PERMIT ISSUE DATE
HAS.-NSEN EDDIA H XR1-12Q-29R
)NEF S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 a
u o p LICENSED CONTRACTOR'S DECLARATION
W 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force and If Z RE-RF RMV EXT SHKS & RPLC W/40 YR COMP 30#FLT CLS
D-z Date Con
Lic.Con A SHNGL 31SQ - J.B.ROOFING CO. PD FOR BUS LIC
Date — — Contractor
ARCHf1ECTS DECLARA ON
ale< I understand my plans shall he used as public records
�ul
`O Licensed Professional
n rn OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct.alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 5q.Ft.Floor Area
UValuation
X (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $13360
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 mere than five hundred dollars(s5M. 31630053 . Q 0
❑I,as owner of the property,or my employees with wages as their sok compensation,
will do the work and the structure is notintended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of q P
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.It,
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.).
[11.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 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:
have and will maintain a Certificate of Consent to self-insure far Workers 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 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 Workers Com enation Insurance carrier and Policy number am:
Carrier. PolicyNo.: 311/1
CERTIFICA F CEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bo completed if the permit is far one hundred dollars($100)
or less.)
I 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 Workcrs'Compenadon
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
Z forthwith comply with such provision or this permit shall be deemed revoked.
Z°'" CONSTRUCTION LENDING AGENCY
Er 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.)
QLenders Name
r7 z Lenders Address
U O 1 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
0 V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-t to 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 UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by:
Mig. u.
R G LATT7- -0 U Re-roofsof Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of R.)of
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.
C1 Yes 9(No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or forum building occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of die
mqu, cors w icIt mu met 'or to issuance of a Certificate of Occupancy. Signature A Applicant Date
t� All roof coverings to be Class%*'or better
r aur anted agent Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT.' RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blh: Lot :
APN . . . . . . . . : 31630053 . 00
DATE ISSUED. . . . . . . : 07/01/2009
RECEIPT #. . . . . . . . . BS000008092
REFERENCE ID # . . . : 09070003
SITE ADDRESS . . . . . : 10546 CYPRESS DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER HANSEN EDNA H TRUSTEE
ADDRESS . . . . . . . . . . : 10546 CYPRESS DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2425
RECEIVED FROM . . . . : ROBERT W SMITH
CONTRACTOR . . . . . . . : TBI) - TO BE DETERMINED LIC # 00096
COMPANY TBI) - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 13 , 360 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 13, 360 . 00 1 .40 0 . 00 1 .40 0 .00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
1REROOFRES SQ FEET 31 . 00 403 . 00 0 . 00 403 . 00 0 . 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 519 .40 0 . 00 519 .40 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 519 .40 MC
---------------
TOTAL RECEIPT 519 .40
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
--�,, CITY OF CUPERTINO 0q0_7 0003
RE ROOF
CUPEkTINO PERMIT APPLICATION
APN # �) Date.
Building A dress:
Owner's Name: Z� vi� ��`� Pone #:
!t �/OO 2 s -7- 3 3v
HOA: Yes ❑ No ® If Yes, provide letter from HOA
Contractor: Phone #: 14W 4 s:2- 6
" ' Fax #: oS
Cupertinft� si ess License #: Contractor License #:
5152-g-)
Type of Rbof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles A Asphalt Shingles
pry Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings ❑ Provide I.C.C.E.S. Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Job De ription: � t _ / �0
30# vu-
a S O L 31
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:,,,
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Z—Val— a
Signature
Revised 02/05/09
CITY OF C"UPERTINO
;;w. REROOF
CITY OF
CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BCBSC Cal Bldg Slandards B ALL PERMIT TYPES
Commission Fee
1BSEISMICO Seismic Commercial B
/ 1REROOFRES Re-roof Residential B 1SFDWLR00F
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1 BSEISMICRE Seismic Residential B
1 REROOFMRES Re-roof Mu Fti-Family B 1MFDWLROOF
1 BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
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 ag-ee to comply with 2007 IBC Standards
and manufacturers specifications on ra-roofing.All roofs are Class "A"per Cupertino
municipal code 16.04.080.
2. New roof coverings shall not be appli,:d without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the b.zilding inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to ar.y 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 mz.terial down to the sheathing,
so a proper City inspection can be per Formed.
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/ "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: ID S a6 r A-A jf�ti,_-� D,
Roofing Company Name: .' A-I—`._ no-
Applicant's Signature:. / Date:
Greg Casteel
Building Official
Revised 07/30/08
M.Indoor Air Quality and Finishes INPUT ResDurces Energy 1ACtHeafth
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes. 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal all E=xposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes N.Flooring innimilld
1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 1 Resource pts y=yes o
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 'I Resource pts y_yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
■ 1 0 1 !
Total Points Available: 140 130 57
Total Points Project Received: . 01 0 0�
G:datalprogslgreer built ingguidelines/remodelers/greenpointsfinal2.12.o4protecied.xls
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of
:UPE�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete 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
PIumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date