12070245 CITY OF CUPERTINO BUILDING PEWMIT
BUILDING ADDRESS: 10165 SWAN OAK I,N COSTRACI'M PIiMRSEN-DIi N INC I' XNI IT NO: 120702.15
OWNER'S NAME': SENNL•ROSEMARYTRUS I-17,C FI Al, 7980 ENT1'I PRISE DR DATE ISSUED:07/308012
OWNER'S PIIOSE: NIiN4\Id R,C\ 94560 PI IONS x0:(510)494-99x2
LICENSEM C0)Y1'R1\CI'OR'S DECLARATION BUILDING PEWNI[l' I NFO: BLDG F_ ELECT PLUMB r_
License Class c--3c, Lic.H_y6glf / r r r
j�,,�, aryl h AI P:CII 12 ESIUP:\TIAL COMMERCIAL
j�
Contractor I C Je_,Aectn/ Done 7_ab l]_
I hereby al7irm that 1 am licensed muter the prvuw'isions of Chapter 9 .)Oli UIiSCRI PITON:TEAR OPT WOOD SI TAKE AND RIT[ACE WIT I COMI'
(Coil]nenci ng with Section 7000)of Division 3 of the isusiness& Professions SIIINGIAI I SQUARES
Code and that ❑rr license is in full Force and effect.
hereby affirm under penally of perjury one of the following ton declarations:
I have and will maintain a cenifcitc of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,f'or the
performance of the work for which this permit is issued.
I have and,will maintain Worker's Compensation Insurance,as provided for by Sq. PI 1'Inmr Area; \';d uatinn:S6357
Section 3700 of the Labor Code,for due performance of the work Ibr which this
permit is issued.
AIT'Number:34232138.00 Ocrugoanc%Type:
APPLICANT CE.R IIICA'iION
1 certify that 1 have read this application laid state than the above infivntation is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representati%es ofthis city to enter PERMIT E\PIRLS IF NVORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the Cily ol'Cupenino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCL OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAS"I- CALLED INSPECTION.
granting ofthis pcnnit. Additionally,the applicant understands and will comply
with all non-point s once regulations per tire Cupertino Municipal Code,Section ^ r1
9.18. ^yj Issued b)s/� Date: j J`ul 2
Signator Date•/ ��� ` ,-
OWNER-BUILDER DEE CLARATION Rh:ROOT'S:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Low for nor of installed without first obtaining an a ppection,I agree to remove all new materials for
the following the reasons: inspection. ��"-"u"N✓.
h a owner of the property,or my employees with wcages as their sole compensmion,
will do lite work,and the structure is not intended or offered for sale(Sea.7044, Si nature f A oolicarit Data:
Business&_Professions Code) `3 —�
I.as owner of the property,am exclusively contracting with licensed contractors to ,
construct lire project(See.7044l Business Professions Code). ALL ROOF CONTIONGS TO If["CLASS"A"OR It f-IT It
I hcrcl)v affirm under penalty of perjury one of the following three
drelarations:
HAZARDOUS>IATIi RIA SDISCLOSI1RE,
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for lire California I lcalth&Safety Colic,Sections 25505,25533.and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance wile the Cupertino\lunicipal Code.Chapter 9.12 and the Health
I have and will maintain Worker's Compensation Insurance,as provided fir by Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices o'hich emit hazardous air
contaminants as defined he the Bay, \tell Air Quality 3lanagemoB District I will
permit is issued. maialain compliance e'ith the Capertinu Municipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued.I shall I Ic:dlh&Safety Code,Sections 255115,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Calilornia. If,alter nuking this certificate ofexentplion,I Ower izeJ agrn l: p I_/ "')
become subject 10 the Worker's Compensation provisions of the Labor Codc,I muss Hate: J C.�
forthwith comph•with such provisions or this permit shall be deenled revoked. 101
COINSfRIICI'10A 1.1•.NDIYG AGENCY
,\I'I'LICANT CERTI EICATICIN 1 hereby affirm that there is a construction lending agency for the performance ofwork's
I certify that I have read this application and state than Elie above information is for which this permit is issued(Sec.3097,Cie C.)
correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name
In building construction,and hereby authorize representatives of this city 10 enter
upon Eire above mentioned property far inspection purposes.(We)agree to save Lender',Address
indemnify and keep harmless the City of Cupcnino against liabilities•judgments.
costs,and expenses whichmay accrue against said City in consequence of the ARCIII'1'ECI"S DECLARATION
of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per tie Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dare
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
:21 ADDRESS: Ipf(�f DATE: 07/30/2012 REVIE\\'ED BY: bobs.
APN: BPI: 'VALUATION: $6,357
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: pPERMITTYPE: 1SFDWLR00
WORK I tear off wood shake and install comp shingles.
SCOPE
l
'llech. Plan Check Plumb.Plop Check Flee.. Plan Check
c tech.Permit Fee: Plumb. Permit Fee: E-Ice. Permit Fee:
Other Mech.Insp. Other Plumb Insp. Ll I Other Eler.Insp.
,blech.lisp. Fee: Plumb. brsp. Fee: Eler./nsp.Fee:
NOTE: This estimate noes not include fees clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District,etc). These fees are based on the prelitninan information available and are onl➢an estimate Contact the Dept for addn'I info.
FEE ITEMS (Fee Resohn ion 11-053 Eff, 7/Ulll FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1,100 s.f. Re-roof
Suppl. PC Fee: Q Reg. O OT 0.0 1 hrs $0.00 $165.00 IREROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Constntction Tax:
Adininisuivive Fee: Q
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fee. -Residential$0.00 SelectaNnn
Trnrel Documentation Fees: Building or Structure Q
i
Strong Motion Fee: IRSEISAIICR $0.64 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
r _ _
_' a
SUBTOTALS;' $1.64 $165.001 $166.64TOTAL FEE:.;
Revised: 07/01/2012
REROOF PERMIT APPLICATION
prk COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228 • FAX (408)777-3333 •buildino5cuDertino.org
CUPERTINO
PROJECT ADDRES-O - ooj I / u APN 0
OWNERNAM°� 1 A) W�JJ� ` L`.•�f PHONE / �`•r E-MAIL
(�1 1
STREET ADDRESS1 0 - / . CRY.`7'STATE:ZIF �_ FAX
CONTACT NAME 1 I PFJ -O�E- 2�/�6_57Z 71 E-MAIL
`
STREET ADDRESS / r�t/ / lCf -fse FAX
11 OWNER ❑ OWNER--BUILDER ❑ OWNERAGENr ABCONTRACTOR �❑JCONTRACTORA4 Nrr 11 ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTrCTCA , AeaIJ ` 't0 _Ot/1/ LICENSE NjI.}1"9117 LICENSE T1'jE BUS.LIC.eA103.0
103 0
COMPANY NAME ( / .J FAX 17 V
STREET ADDRESS ClY.STATE ZIP PHONE
7 9ro��rIsc Of- E-MAILi R y56G
ARCHITECT/ENGMEER NAME LICENSE NUMBER BUS.LIC.X
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
USE Of ❑ SFD or Duplex Multi-Family ROOF AREA: VAL//U'ATION: UU
STRUCTURE: E] Commercial /0,7/s
0{ ,7/s b 3 S 7/
EXISTING ROOF TYPE: ❑BUILT-UPROOF ❑ASPHALT SHINGLES -+WOOD SHAKES ❑WOODSHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACEnYES I IF NO. PLYWOOD �Y" ❑ PLYWD `p OSB PITCH: ROOF
❑NO 9LAVERS THICKNESS' ❑ SB" TVPB ❑COX 'i2 CUSS: A
PROPOSED ROOF TYPE: ❑BUILT-UPRODF XASPHALT SHINGLES ❑WCIODSHAKES ❑WOOD SHINGLES OTHER ICC-ES REPORT a
135G
DESCRIPTION OF WORK: RemovL / •� �( I_ ' ( p I C I ILn
V / (l�X.O 1/yG K /� S-t �C-CSIC.IC'.0 l4 J(n f/0 f l�
�Vela Z R4J t P/ 600 6 FC
By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have pro✓ ed is correct- I have read the Description of Work and verify it is Decorate. I agree to comply with all applicable local
ordinances and stale laws relating to i .v w auction. authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: �/ Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USEONLY. -
_If building is associated with a Home Ow'ner's Association,provide letter PLAN CHECKTYPE "�" ROUTING SLIP
of approval from HOA. - I,coUNTER •, B� UILDINC,PIAN REVIEW
_Provide Planning approval to verify if there any restrictions. ❑ EXrRESS I•. ! ❑ PLANNING'PLAN REVIEW'
Provide copy of Manufacturer's Installation Specifications.
❑ STANnARD" ❑ FIRE DEPT
Zf-
rovide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER.:
ReroojApp_2011.doc revised 03/16/11