12090034 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21105 WHITE FIR CT CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 12090034
OWNER'SNANIE: WATSONTHOMASD PO[ION 1668 DA'Z'E ISSUED:09/062012
OWNER'S POONE: 4082537740 SAN JOSE;CA 95109 PHONE NO:(408)278-0330
❑ LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1- ELECT r PLUMB IJ
License Class? Lie.H tl 217/0 0 r r I-'
n MEC11 RESIDENTIAL COMMERCIALContractor /`— Date
hereby affirm that l'am licensed under the provisions of Chapter J013DESCRIPTION: RIiROOF 13 SQ TEAR OFF WOOD SHAKE AND INSTALL
(commencing with Section 7000)of Division 3 of the Business& Professions CLASS
Code and that my license is in full force and effect. A COMP SHINGLES
hereby affirm under penalty of perjury one of the following two declarations: h
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 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 die work for which this Sq.Ft Floor Area: Valuation:54500
permit is issued.
APPLICANT CERTIFICA'T'ION APS Number:35905082.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct. I 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
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep hmmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point ource regulations per the Cupertino Municipal Cod ;S ction
9.18. / -7
Issued by: ��/� ��!'G�/ Date:
Signature
Cl OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material be hg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to removeall new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection. �J
will do the work,and the structure is not intended or offered for sale(Sec7044,
. A`�
Business&Professions Code) Signmure of Applicant: GLj'e-� Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business R Professions Code). ALL ROOF COVERINGSTO BE CLASS"A"OR BETITR
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MAT'FRIAI S DISCLOSURE
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 I have read.the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California health&Safely Code,Sections 25505.25533,and 2.5.534. 1 will 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 Uealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality'Management District I will
I certify that in the performance of tie work for which this permit is issued,Ishall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to die Worker's I lealth&Safety Code,Sections 25505,25533�WF
and 25534
Compensation laws of Cal ifamia. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner o�uth�rized apes_ _forthwith comply with such provisions or this permit shall be deemed revoked. `�� _ Data
CONSTRUC1•ION LENDING AGENCY
APPLICANT CERTI FICATION
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 for the performance of work's
correct.I agree to comply with all city and county ordinances and state Imus relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city m 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 ARCII ITECF'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
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21105 WHITE FIR CT DATE: 09/05/2012 REVIEWED BY: MENDEZ
APN: BP#: 'VALUATION:
*PERMIT T1'PE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: I I PERMIT TYPE:
WORK RE-ROOF 13 SQ TEAR OFF WOOD SHAKE AND INSTALL CLASS A COMP SHINGLES
SCOPE
FEEID ROOFAREA
s.r.
1REROOFFRES 1,300
,Meeh. Plan Check Phunb. /'Inn Cheek F.lec. flan Check
htech. Permit Fee: Plmnb. Permit Fee: Dec.Permit Fee:
Other•,ifech./nap. Other Plumb Insp. L1 I Other Elec.lnsp.
Me.ch.hr p. Fee: Plumb. bryr.Fee: Elec.Insp.Fee:
A'OTE: This estimate does not include jeer due to other Departments(i.e. Planning Public li'orks, Fire,Sanitaq'Server District,School
District, etc). These fees are based on the prelinsinan•in oratation available and are onh,an estimate Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/11) FEE QTY[FEE MISC ITEMS
Plan Check Fee:
S'uppl. PC Fee
Phinib./ddech./Elec
Permit Fee: $195.00
Suppl. lnsp Fee
P1umb./Meeh./Elec.
Plunih./A-lech./Elee Permit Fee:
e:
Construction Tits:
Administrative Fee:
Work Without Permit? O Yes (F) No $0.00
Advanced Planning Fees:
Travel Documentation Fees:
Strone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $196.50 $0.00 TOTAL FEE: F$196.50J
Revised: 07/01/2012
f �
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION '
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333•building(cDcuoertino.org
,
PROIECTAODRESS APN• O"�./ /uU
Z os P-
OWNER NAME r I PHONE E-MAIL
w a asa-
STREE'rADDRESS�I O� C I CIT' STATE,LIP I FAS
CONTACT NAMF. PHONE E-)TAIL
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STREET ADDRESS 5,02 warrilaqS CITY.STATE ZIP&LA FAX
❑OWNER ❑ OWNER-RUILDER ❑ OUTER AGENT J( CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTORNAMELICF.NSENL'\IBER _77.1 LICENSE 'PE BUS.LIC.
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COMPANY TIME E-MAIL FAX
5
STREET ADDRESS CITY.STATE.21P PHONE
S07 a ckse C - B'O
.ARCHITECT-ENGINEER NAME LICENSE NUMBER BUS.LIC.
CONIP\SYSAME - I E-aIAIL FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
,/
LSE OF ❑ SFD or Duple\ /Ir Multi-Family ROOF AREA: Ell VALVATION:
STRUCTURE ❑ Commercial 56k. SQ
EXISTING ROOF TY PE: ❑BUILT-CPROOF ❑ASP[ALT SHINGLES 0WOODSHAAES ❑WOODSHINGLES ❑OTHERISPECIFYI
REMOYF.:REPLACE YES I IF N0. - PLV\VOOD ❑ PL1'\\'D ❑OSB PITCH: )2 ROOF
❑ N . A\'F.R
THICKNESS ❑ .'- TYPE' CLASS
IMES REPORT•
PROPOSED ROOF TYPE! ❑BCILT-UP ROOF 4SPMALT SHINGLES ❑\\'OOU SHAKES ❑\I OOD SHINGLES ❑OTHER
DFSCRIFTIONOF\t ORKt
84
.l*
e
PcomfreslAeft4m.1b
Ay my signature below.I certify to each of the following: 1 am the property owner or authoriud agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state WAS relating to building con�tion. I a' orize represswtivg of Cupenino to enter the above-identified property for inspection purposes.
Signature of ApplicandAgent: Date:
19 / 61012
SUPPLEMENTAL INFORMATION REQUIRED 77 OFFICE USE ONLY
_If building is associated with a Home Owner's Association.provide letter PLANCHECK TYPE ROUTINC SLIP
of approval from HOA. ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
_Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLANN INE PLAN REVIEW
_ Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD ❑ FTRE DEPr
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
ReroofApp_2011.doc revised 03116/11