12080295 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21087 WHITE FIR CT CONTRACTOR:FOUR SEASONS ROOFING PERDIFTNO: 12080295
OWNER'S NAM F,: LIN CHANG CHING TRUS'T'EE&ET AL 1'0 BOX 1668 DATE ISSUED:08292012
OWNER'S PHONE: 4087490475 SAN JOSE,CA 95109 PHONE NO:(408)278-0330
a LICENSED COMI'RACI'OR'3 DECLARATION BUILDING PERMIT INFO: BLDG C, ELECT IJ PLUMB rl
License Class C-gti Lic.9 Lf?AfDO
M ECII r RESIDENTIAL❑ COMMERCIAL r
Contractors (�-r'..l C . Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF WOOD SHAKE AND INSTALL 13 SQFT CLASS A
(commencing with Section 7000)of Division 3 of the Business& Professions COMP SHINGLES
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
1 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 Sq.Ft Floor Aren: Valuation:$4500
Section 3700 of the Labor Code,for the perfomtance of die work for which this
permit is issued.
APN Number:35905073.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulatims per the Cupertino Municipal Code.Sectiat _
9.18. / Issued bv: �F�/✓ r/-/ G!,/1
Date: %a
Signature Date 8-29-/2
r
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to my roofing material beiig installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all nnv materials for
the following two reasons: inspection.
I,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, Signature of Applicant, Date:1��2
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF CO\F,RINGS TO BF,CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS MATF-RIALS DISCLOSURE
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 die Labor Code,for the California health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Boy Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25.534.
not employ my person in my manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or a th if, •ab211 L' C �'��
become subject to the Worker's Compensation provisions of the Labor Code,I must ata %Z
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'1'RI1C1'ION LF:\UINC AGENC\'
APPLICANT CERTIFICATION 1 hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may acerae against said City in consequence of the ARCHITEM"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be.used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS:.�4101(' White fir ct. DATE: 08/27/2012 REVIEWED BY: bobs,
APN: BP#: 'VALUATION: $4,500
*PERA1IT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1SFDWlR00
WORK tear off wood shake and install comp shingles.
SCOPE
blech. flan Check Plumb. Plan Check Elec. Plan Chock
Mech. Perwh Fee: Plumh.Permit Fee: Elec. Permit Fee:
Other Hoch.Insp. Other Plumb Insp. Other Elec.Insp. Ll I
,Meth.Insp. Fee: Plumb. Insp.Fee: Elce.Insp.Fee:
NOTE: This estimate does not include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelintinan information available and are oah,an estimate. Contact the Dept for addtt 7 info.
FEE ITEMS (Fee Resolution 11-053 ETf 7/1/11) FEE QTY/FEE ]MSC ITEMS
Plan Check Fee: $0.00 1,300 s.f. Re-roof
Suppl. PC Fee: (D Reg. Q OT 0.0 Itrs $0.00 $195.00 IREROOFREs
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consrr7tciion Tax:
Administrative Fee: O
Work Without Permit? O Yes Q No $0.00 0
Advanced Plannine Fee: $0.00 Select a Non-Residential 0
Building or Structure 0
Travel Doctuneniorion Fees: A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Pee: 1BCBSC $1.00
T_SUBTOTXLS;. $1.50 $195.00 TA
TOL FEE $196.50
Revised: 07/01/2012
I
REROOF PERMIT APPLICATION
COMMUNITY,DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CIJPERTINO (408)777-3228• FAX(408)777-3333•buildino(cDcupertino.oro
PROJECT:\UDRE55Z/O F e .TPS• /ct' O
OWNER NAME PHON4 J EMAIL y
/GL OB
STREE r ADDRESSZ-/09'7 ^ C CI STATE.ZIP M I FAX
IL J�+ i
CONTACT NAME PHONE EMAIL
-0
STREET ADDRESS 5'07- S CITRST.AI'E.IIP FAX
❑O4'NFR ❑ OWNER-BUILDER Cl OWNER.AGENT ACONTRACTOR ❑CONTRACTOR AOENR ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRA(-TORNAMELICENSENCMBER LICENSE 'PE_SgBUS.LIC.•
11V 08
COMPANY NAME E-MAIL FAX
STREET ADDRESS�OZ CITY.STATE.ZIP Q OSQ. ^ PHONEe)q -O
ARCHTTECT,E.N NEER NAME War Wi LICENSE NUMBER fs BUS.LIC.-
COMPANY NAME EMAIL FAX
STREET ADDRESS CITY.STATE ZIP PHONE
USE OF ❑ SFD or Duplex j{ Multi-Family ROOF AREA: �/ VALUATION: p
STRUCTURE: Cl Commercial 13 S SO
EXISTING ROOr TYPE! ❑BUILT"OP ROOF ❑ASPI(,ALT SHINGLES r�ar/r wOOD SHAAHS ❑WOODSHINGLES ❑OTHER(SPECIFY)
RENIOYF,:REPLACE JVYES IF NO. I PLYw' D t ❑ PLYWD ❑OSB PITCH, ROOF
❑R -LAYERS' T AC SS ❑ 518- TYPE- 712
PROPOSED ROOF TYPE: ❑BUILT-UPROOF leASPH.ALTSHINGLES 0w0ODSHAKES ❑wOODSHISGLES ❑OTHER ICC-ES REPORT.
DESCRIPTION OF WORNt lA l f
e
•! •p 6
By my signature below.I 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 provided is correct, 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating To building cons tion. I a rize reprnS ti%,2 of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agtir Date: g 0
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
_ If building is associated with a Home Owner's Association.provide letter r PLAN CHECK TYPE r�ROUTING SLIP
of approval from HOA. oC1 VER-THE-COUNTER BLJ UILDINC PLAN REVIEW
—Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Provide.copyof Manufacturer's Installation Specifications. ❑ STANDARD ❑ FIREDEPT
oxide signed copy of Cupenino's Tear-OR Policy. ❑ OTHER:
Reroof.4pp_201 l.doc revised 03/16/11