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12090027 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21611 COLUMBUS AVE CONTRACTOR:RIDGETOP ROOFING INC PERMIT NO: 12090027 O%VNER'S NAME: WU DONALD S AND GINA C 1350 DELL AVE DATE ISSUED:09/05/2012 OWNER'S PHONE: 4083938608 CAMPBELL,CA 95008 PHONE-NO:(408)370-3332 ❑ LICENSED COM1 TRACTOR'S DECLARATION •JOB DIiSCRIPTION: RESH)ENHAL COMMERCIAL. CI License Class Lic.M �7� S 6 RE-ROOF 34 SQ TEAR OFF SHAKES, INSTALL METAL TILE Contractor a e �ltJri{fUD Cpff, L CLASS A hereby affirm that I am licensed under the provisions of C apter 9 (commencing with Section 7000)of Division 3 of the Business S Professions Code and that my license is in full force and effect. hereby affirm under penalty of perjury one of the fnllmring two 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. Sq.Ft Floor Area: Valuation:$21000 1 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 APN Number:35618031.00 Occupancy Type: permit is issued. APPLICAN"I'CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state Imus relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY OM LAST CALLED INSP7�11el N. m indenify and keep harmless the City of Cupertino against liabilities,judgments, , costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: nDate: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE:ROOFS: Signator Date t_, All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION - - Signature of Applic Date: hereby affirm that I am exempt from the Contractor's License Law fur one of the following two reasons: ALL ROOF COVERINGS T E CLASS"A"OR BETTER 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(Sce.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sce.7044,Business K Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: I Iealth S Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code•for the air contaminants as defined by the Ray Area Air Quality Management District 1 performance of the work for which this permit is issued. wi11 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth X Safety Code,Sections 2550 2 5 ,and 2553.1. Section 3700 of the Labor Code,for the performance of die work for which this Z Owner or authorized agent: permit is issued. I certify that in the performance of the stork for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application mid state that the above information is correct. I agree to comply with all city and county ordinances and state lases relating to building construction,and hereby authorize representatives of this city to enter upon die above mentioned property for inspection purposes.(We)agree to save indemnify and keep hamiless the City of Cupertino against liabilities,judements, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21611 COLUMBUS AVE DA'Z'E: 09/05/2012 REVIEWED BY: MENDEZ APN: BP#: 'VALUATION: $21,000 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PENTAMATION PRIMARY SFD or Du lex 1SFDWLROOF USE: P PERMITTYPE: WORK RE-ROOF 34 SQ-TEAR OFF SHAKES INSTALL METAL TILE SCOPE FEE ID ROOFAREA s.f. 1REROOFFRES 3,400 I blech. flan Check Plumb. Ilan Check Elec. Plan Check Mech.Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: Other Mech.Insp. Orher Plumb Insp. Other Elec.Lap. Meth. Insp.Fee: Plumb. hup.Fee.: Elce.Insp.Fee: NOTE: This astimate does not include fees due to other Departments(i.e. Planning, Public IVorks, Fire,Sanitary Sewer District,School District,etc. . Thane feev are baser/on the prelitninan information available and are only at estimate Contact the De t or addn R info. FEE ITEMS (Fee Resolution 11-053 Lff 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee At Phunb./dlech./Elec Permii Fee: $510.00 Suppl. Insp Fee PlumbAllech./Elec I'lumb.11lechlElee Permit Fee: Conslrticdon Tax: Administrative Fee: Work Without Permit? 0 Yes No $0.00 A(Awneed Planning Fees: Travel Doctunentation Feer: Strong;Motion Fee: IBSEISAIICR $2.10 Select an Administrative Item 131d¢Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $513.101 $0.001 TOTAL FEE: $513.10 Revised: 07/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228•FAX (408)777-3333•building(Mcuoerfino.org ❑NEW CONSTRUCTION El ADDITION ❑ ALTERATIONVII ❑ REVISION/DEFERRED ORIGINAL PERMIT# YROII:CT ADDRESS / / �11 Us /t� APNMoe OWNER NAME I^ W N PHONE V4 STREIT ADDRESS .r/ CITY. STATE ZI � FAX 3�o 33 CONTACT NAME A r/ Pf10NL' 3�� rJ� EMAIL`�� r car& r STRERTADDRESS /� `�` •'T - `rI� J lJ PA�J�'1 _ 35-3 ❑OWNER ❑ OWNER.mnucFR -f.❑1 OWNERAGENT CONTRACTOR ❑CONIRACIORAGFM ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEIJANr CONTRACTORNAMF/,1 O A J7 l�� LICFNSENUMBER (�� LICEN�j TYPE BUS,LICK COMPANYNAME r�, ( ry�� GMAII, 7^! , �z(�� ` ' t 2940-5-75D 9D _ —75D (19_ 5"rxl?irl'AUUxESS `�( CI'1'Y,S TI,%IP PHONE .322 —33 ARCHITECUEN'GINEER NAME S, LICENSENUMBER BUS.LICK COMPANY NAME E-MAIL FAX STREET ADDRESS nn CITY,STATE.ZIPPHONE DESCRIPTION OF WORK // — O z '� -r,,(, 4 30 :c EXIS'I'INGUSL' I PROPOSED 115E CONSTRt TYPE I MS'FORIIS USE TYPEOCC. SQ.FT. VALUATION(S) ECISFG NEW n.00R DEMO TOIAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER RCMODELAREA REMODEL AREA REMODELARE\ POROi AREA DECK AREA TOTAL DECK/PORCH All GARAGE AREA: DETACH ❑ATTACH #DWEWNG UNITS: ISASt:CON'Dtl.Nll ❑N'ES ST.COXDSroRY ❑YTS BEINC,ADDKD! []NO ADDITION? ONO PRE-APPMGTION ❑\TS IF YES.I'ROVIDii COPY OF IS Illy.BLD(;AN ❑YTS RIiCE EU �q VALUATION: PENNINGAPPL# ❑NO PLA GAPPROVALI.HTMR F.10H.F:RHOME? ❑NO . '/� 000 fly my signature below,I certify to each of the following: I am the property owner or authonnd ent to act on the property owner's behalf.. I have read this application and the inlbrmalion I have provided is correct. I have read the Dcuriptinn of Wurk d verify it is accurate. I agree to comply with all applicable Ionil ordinances and state laws relating to build' g coatlm tion. I au llorf a re natives of CupRriino to enter the abovo' entiTq property for inspection purposes. SignaturcofApplicanVAgcmC bale: W 2 SUPPIXMIiN'I'AL INFORMAT RE Iia 1'IdN CHECK TYPE RlllrrlNC SLIP New SI'D or Multifamily dwellings: Apply for demolition permit for OVER-TIIF.C:OENTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of buildin permit for new building. fr ❑ EXPRESS ❑ PI.ANNING PLAN REVIEW' _Commercial Bldgs: Provide a completed I lumdous Materials DISCIOSUEE ❑ STANDARD ❑ PUBLIC W'o RKS Tom if Bay Hazardous Materials am:being used as part of this project. ❑ L\Rre ❑ Flxe uerr _Copy of Planning Approval Letter or Meeting with planning prior to submittal of Building Permit application. ❑ MAJOR 1:1 sANrGRYseweR msrRlcr ❑ EN'vmHN:MFNTAL HEALTu Bldgdpp_201 Ldioc revised 06/21111 1 ,