12070028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 923 ROSE BLOSSOM UR
CON'IMItACI OR:'PBB
W —{'E){�{�}Fk{.H+I(.}(•} NI{R\IIT\0: 1207002X
ONER'S NANIE: CAROLI:FON �/�/ rl�-�Od
CeC DA fK ISSUr:D:07:052012
OWN'ER'S PHONE: 4088215183 53 — Puost:No:
❑ LICENSED CON"TRACTOR'S DECLARATION 'Sj zA—
/ BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class q� Li . ���. ��
Contraclor -- - Dale- - _ d le 1r1ECI1 RESIDENTIAL r COMMERCIAL r
I hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION: RI;MOvli WOODSI IARliAND INS"I ALL OSB I'L1'w'000 1/2
(commencing with Section 7000)of Division 3 of the Business&Professions IN
Code and[lint my license is in full force and effect. RLROOP I)Y-1'IMBERLIN'li IID LIFI�TIMI:
1 hereby'affirm under penalty of perjury one of the following two declarations:
I have and will nlaimain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the labor Code,for the
perfbrnumee til the%cork for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ol'Ihe Labor Code,for the performance of the work for which this Sq.Ft Floor Area: \'ahtalion:58000
pernit is issued
APPLICAN"f CERTIFICArill ON \PN\'umber:35903033.00 Occupalln frpc:
I cerlil%that I Rade read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating
to building cunuruction,and hereby aulhorize representatives of this city to enter
upontheabode eephanedpruperC yOfCpcciionpurposes.stl (Wc)agreees,ju to sant PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify:mJ keep harmless the City ofCupenino against liabilities,judgments,
costs.and expenses which may accrue against said City in consequence ufthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granlingufthispermit.sour Additionally,per
he Cupertino
Municipal
al Code,
comply 180 DAYS FROM LAST CALLED INSPECTION.
with all nun-point source regulations ptrthe Cupertino Municipal Code,Scclion
9.18. —0/u
Signature Issued by: Date:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RF:ROOF'S:
All roofs shall be inspected prior to any roofing material being installed Ifo roof is
the following two reasons: installed without first obtaining an inspection.I agn
L as owner Of the properly.or my employees with wages as their sole compensation, inspeCdom ree to renutec all new nuuei uts far
will do the work,and Elie structure is not intended or offered for sale(See.7044,
Business&Professions Code) Signature orApplicant: Date:
L as owner of the propcny,ant exclusively contracting with licensed contractors to
construct the project(Sec,7044.Business&Professions Codc),
ALL ROOF C0\'EI(IN(;S'I'0 BE CI„\SS”,\"()It HE]'I Ell
I hereby affirm under penalty of perjury one of the following three
declarations:
I have unit will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS NIA'I FRIM S DIS('1 OS(IRF'
Contpcnsation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6A5 of[fit,
perlmoinoce of the work for%%Inich this permit is issued- California Ilealth&Safety Code.Sections 255115,25533,and 25534. 1 will nminlain
1 have and will maintain Worker's Compensation Insurance,as provided 1'or by compliance%%ilh the Cupertino>Iunicipal Code,Chapter 9.12 and the Ilealth
Section 3700 of the labor Codc,for the performance of the work for which this Safety Code,Section 25532(a)should I since or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices.which emit hazardous air
I certify that in the purlominnce 01-the work for which this permit is issued,I shall contaminants as defined by the Ba)Area Air Qllallt)'?lanagcnt'nt District I%will
maintain compliance with[he Cupertino,\lumcipal Code,Chapter 9.12 and the
not employ an) person in any manner so as to become subject to die Worker's Health&Safety Code,Sections 25505,25533•and 255341.
Compensation laws of California. If,after making this certificate of exemption,I /
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized nem/
forthwith comply with such provisions or this permit shall be deemed revoked. I 111 Date:
A PIII,ICAN"I'CERTIFICArill 0N CON'S'I1l(l1( 170N LENDING AGFNcN'
I eerily that 1 have read this application and state that ilia above information is I hereby al7inn that there is a construction lending a!_enc% Ito the perfinnuanec of work's
correct. I agree to comply%%'ith all city and county ordinances and slate laws relating for which this permit is issued(Sec.3097.Civ CJ
to building construction,and hereby aulhorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep hnnnless the City ol'Cuperlino against liabilities,judgments. Lender's Address
costs,and expenses which may accrue against said City in consequence of tile
granting of this permit.Additionally.the applicant understands and will comply
with all non-point source regulations per Ole Cupertino Municipal Codc,Sectinn ARQ l I'IIF-CT:S BF,CL:Ote\PION
1 undcrstantl my pians shall he used as public records.
Signature (late Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 923 rose blossom dr. DATE: 0710512012 REVIEWED BY: bobs.
APN: BP#: ' oZt)�7Xc;Z 0 'VALUATION: $8,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration I Repair
PRIMARY SFD Of Duplex PENTAMATION 1SFDWLR00
USE: PERMIT TYPE:
WORK sfd remove shake install comp shingles.
SCOPE
.11r<h_ l'lnn�'Ldr;d l'lrunh. /Yon Cho A lil,a:. Ph"?(7x,k
,17.E lr l'awil Frr_ Nu,n6, I'Ci>ni,h;r: dr_
P:I1'ernri,h;r.
11/w, 1h,12. be+p. O(her Minn),Ine'p. O:Avr tiler. Gup. ET
Ihr,h. bnp_ Fr,-: l'hnnb. b)"p. Fe'. har,, I"'i, /:i"
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De 1 or addn'l info.
FEE ITEMS (Fcc Resolution 11-053 Eff' 711//1) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 2,550 s.f. Re-roof
Suppl. PC Fee: Q Reg. 0 OT O.0 hrs $0.00 $390.00 IREROOFRF.S
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. FeeS. Reg. Q OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
( onsl)xr tion Tal
;Wnuni,n,16w
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Pee: $0,00 Select a Non-Residential E)
7 r,n°rl /Jnr�unr,:rulii nr /-ccs: Building or Structure O
I
Strong Motion I cc: IBSFISMICR $0.80 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.80 $390.00 TOTAL FEE: $391:80
Revised: 07/01/201
//`> U
0'r,q
LMREROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION Uzi
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
C U PERTI N O (408)777-3228• FAX(408)777-3333•building(�cuoertinG.Dm
PROTECT ADDRESS A16 fe / (•1/i�f�I �-!�/ .{PN
OWNER NAME ,r n/l� ` _��l✓/(J / CCC---"PPHONE ('O � .� �Q�L E-MAIL
STREET ADDRESS .'G(I` CITY, STATE.ZIP FAX
CONTACT NAME PHONE EMAIL
v`4
STREET ADDRESS ,yr CRY.STATE, ZIP FAX
11 OWNER C1 OWNER-BUILD ER ❑ OWN-ERRA�GENTT ^ly CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME h� `�//7 / / ZL// L0.-ENSE NIIt•�ERI. - �I//O LICENSE TYPE 2�/'� BUS LIC.a �jC��-�
COMPANYNAME /� 1 V / E-0IAIL /�/ -. i�l /J��/�C% 7L/1�Y•/> FAX
STREET.ADDRESS JJ-7// �7/J L� /\ L � C� Cm•.STATE ZIP �II 67TIl PHONE GUJ��
ARCHITECLENGINEER/NAME LICENSENtIMBER ✓\ f BUS.LIC.a
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
11SE OF SFD or Duplex ROOF AREAV.LLUATION. i
sraucrtmE. ❑ Conunercial
EXISTING ROOF TYPE. ❑BIIILT-UP ROOF ❑ASPHALT SHINGLES WOOD SHAKES WOOD SHING LES ❑OTHER(SPECIF YI
REMOVE/REPLACE YES IF NO. PLYWOOD w. ❑ PLYWD 05B PITCH: !� ROOF
❑ NO a LAYER ❑ ,4. M � ❑ IDX J :�, .Ass 'a
PROPOSED ROOF TYPE- ❑BUILT-UP ROOF ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER -K S MPORT a
DESCRIPTION OF\VORK:,� _y Q iU / /r�� /' 1/' �'ry t✓/ - / /
By my signature below,1 certify to each of the f owing: 1 am the property owner or authorized agent to act on die property owner's behalf. I Imve read this
application and the information 1 have provided Is tgrrcr:t. [have read the Description of Work=d verify it is accurate. I agree to comply with all applicable local
ordinances and slate laws relating to builAs c JmtV-u—ion. I authorize representatives ofCupertino to enter the above-identifie ropeny for inspection purpose.
i
Siglwture of Applicant/Agent: L �i Date: i
SUPPLEMENTAL INFORMATION REQUIRED OFYTCE USE ONLY
_if building is associated with a Home Owners Association,provide letter PL{NCHECKTYPE �ROUTINGSLIP
ppl'Oval
ofafrom HOA. OVER-THE-COUNTER � BU1
� LDING PLAN REVIEW
Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PWNNING PLAN REVIEW
_ Provid copy of Manufacturer's Installation Specifications. C1 STANDARD ❑ FIREDEPT
rsigned copy ofCupertino's Tear-Oft-Policy. ❑ OTHER:
Reroof l pp_2011.doc revised 03'16/11