12080035 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 20630GARDENSIDECIR CON'1'R,\CI'OR:BRADSIIA\VR0017INGINC PERMITNO: 12080035
OWNER'S NANI E: JACKLIN KELLY 1821 S BASCOM,\VE I'MB 160 DATE ISSUED:08/072012
OWNER'S I'IIONE: 4082469930 CAVI PRE I'll.CA 95008 PHONE NO:(40S)2469930
❑ LICENSED CO\TRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C_ Lic.a:?Q r r r
�.�` DI F,CIi RESIDENTIALr-
7�1W Da1e/7/2
1 hereby affirm that I run licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE EXISTING ROOF SYSTEM AND INSTALL NEW
(commencing with Section 7000)of Division 3 of the Business.f Professions CLASS
Code and that nnlicense is in full force and effect. A ASPHALT SHINGLES, 12 SQUARES
hereby affirm under penalty or perjury One of rhe following Iwo declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq. Fr Floor Aren: Valuation:$6000
permit is issued.
APPLICANT CERTIFICATION AI.N Number:36232043.00 Occuponcy Type:
I certify that I have read this application Enid state that the above information is
correct.I agree to comply with all city and county ordinances mid state laws relating
to building construction,mrd hereby authorize representatives of this city to enter
upon tire above mentioned property lhrinspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAPS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,[lie applicant understands mid will comply
with all non-point source regulr
ations per Cupertino Municipal Code,Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18. _ /
((/7/�2 Issuer) by: �`i i�✓ Gl� Date:
e
Signatur Dat
❑ OWNER-BUILDER DECLARATION'
IIF-I200FS:
hereby affirm that I am exempt front rhe Cmuractnr's Lieense Lao for One Of All roofs shall be inspected prior to am roofing material beitg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all nese materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business R Professions Code) Signature of Applicant: Date:
I,as owner of Ore property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business R Professions Code). AI,1,ROOF CO\'Ii121NGs TO BE CLASS"A"OR REITER
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Cenificate of Consent to self-insure for Worker's IIA%ARDOUS NIATERIAI S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California I leallh S Safety Code,Sections 25505,'_5533,and 25534. 1 mill maintain
I have and will maintain Worker's Compensation Insurance•as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the llealth&
Section 3700 of the Labor Code,for the performance of the work.lbr which this Safety Code,Section 25532(n)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in Elie performance of true stork Ibrsvhich Oris permit is issued,I shall maintain compliance with(lie Cupertino Nlmmicipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's I leal Ih\Safely Co;94d�
ions 25505,25533,and 25534.
Compensation laws of California. If,aficr making this certificate of exemption.I
become subject to the Worker's Compensation provisions of rhe Labor Code,I must t vn pr u ori' : Y�J
forthwith comply with such provisions or this permit shall be deemed revoked Date, �+
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency f'or the performance of work's
correct.I agree to comply with till city and county ordinances End state Imus relating for which this permit is issued(Sec.3097,Civ Q
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
12 FEE ESTIMATOR - BUILDING DIVISION
1'ikk
DDRESS:?O - �y DATE: 08/06/2012 REVIEWED BY: Beth
PN: BP#: 0 0 00.3.5 I *VALUATION: $6,000
*PERIMIT 1'YPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAD1ATION
USE: SFD or Duplex PERMITTYPE: 1SFDWLROOF
WORK remove existing roofs stem and replace with Class A asphalt shingles
SCOPE
FEEID ROOFAREA
(s.f.)
1REROOFFRES 1,200
Alech.Plan Check Phunh. Plan Check Elea Ilan Check
htech.Permit Fee: Plumb.Permit Fee: @ler. Permit Fee:
Other Ateeh. Insp. Other Plumb hasp. Ll I Other Eler. Insp.
Afech. Insp. Fee: Plumb.Insp. Fee: £ler. lisp. Fee:
A'OTC: This estimate aloes not include jets alae to other Departments(i.e. Planning, Public IVorks, Fire,Sanitaq Server District,School
District, etc.). These fees are based on the preliminarl information available and are onfr an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (FeeResohnion 11-053E(T 7/1/11) FEE QTl'/FEE MISC 1TED1S
Plan Check Fee:
Suppl. PC Fee
Plarnb.AVIech./Elec
Permit Fee: $180.00
Suppl. Insp Fee
PhimbAllech.lElec
Plu1th./A4ech./E1ec Perniil Fee:
Construction Tax:
Administrative Fee:
Work Without Permit? 0 Yes 0 No $0.00
Aclvunced Planting Fees:
Travel Documentation Feat:
Strong Motion Fee: IBSEISAIICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC 1 $1.00
1 1
SUBTOTALS: 1 $181.601 $0.001 TOTAL FEE: 1 $181.60
Revised: 07/0112012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
C U P E RTI N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT# / D
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: ;Z VA et, e V t CITY/ZIPCODE: S ose $
*Our municipal code requires all businesses working in the city to have a City of Cupertino-business license.
NO BUILDIiN'G 'FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
4
REROOF TEAR-OFF POLICY
2 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE• CUPERTINO,CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333•building(akupertino.ora
PROJECTADDRESS O APN N r� ^O�
OWNER NAME �1 ^ PHONE E-MAIL
STREETAO FAX
O Clf a H
CTO NA.fE LICENSE NUMBE LICENSE TYP BUS.LIC.a
I 1� t
COMPANYNAME E•MAl (^C' FAX y� _
STREET ADDRESS CITY,STATE.ZIP HONE
I UNDERSTAND AND AGREE TO THE FOLLOWING:
1. The re-roof project shall comply with all applicable provisions of the 2010 California Codes.
2. An inspection request can be scheduled up to the day before the inspection date. Please call (408)777-
3228 from 7:30 - 3:30pm (Mon-Thurs) or 7:30 - 2:30pm (Friday) to schedule the next day inspection.
For Tear-Off and Nailing Inspections, you must also call on the day of the inspection only after that
phase of the work is completed. The building inspector will be available within one hour. Progress
and Final Inspections will be given a two hour window.
3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked-down or removed prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the
building inspector. Any roofing which is applied without first obtaining an approved inspection will
require the removal of all new material down to the sheathing so a proper inspection can be performed.
6. Progress Inspection is required when approximately 50% of roof covering is installed.
7. A Final Inspection and aoproval shall be obtained from the building inspector when the re-roofing is
completed. To receive a final sign-off, the following items will be verified:
a. Flat roofs shall have a minimum of I/<" per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre-manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
8. NOTE: .If you call for a tear-off or plywood nailing inspection and the work is not complete, you will be
charged a re-inspection fee of S 126.00. The re-inspection fee shall be paid before another inspection
can be scheduled.
By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act on the
property owner's behalf. I understand and agree to comply with the re-roof policy stated above. 1 also understand that
smoke detectors and carbon monoxide detectors are required to be installed in accordance with Sections R314 and R315 of
the 2010 California Residential Code
Signature of Applicant/Agent: Date:
Rep-oofPolicv_1011.doc revised 01/16/11
Rerwf fpp_?011.doe revised 03,'161 11