12090039 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21095 WIIITE FIR CT CO\1'RAC-FOR:FOUR SEASONS PERMIT NO: 12090039
ROOFING
OWNER'S NAME: 110 YU HUA TRUSTEE PO BOX 1668 DATE ISSUED:09/102012
OWNER'S PDONF,: 4088651219 SAN JOSE,CA 95109 PHONE NO:(408)278-0330
I'a' LICENSED CO\IRACI'OR'S DECLARATION JOB DESCRIPTION: RESIDE\PIAL El COMMERCIAL
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License ChtssC-3� Lic.97 0�(�8 RE-ROOF 13 SQ TEAR OFF WOOD SHAKE AND INSTALL
CLASS A COMP SHINGLES
Contractor Date q—1Q!:1
hereby affirm'hot I am licensed under the provisions mf Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and.[balmy license is in full force and effect.
hereby affirm under penallyal"perjury one of the following 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: valualion:54500
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
,1P\Number.35905077.00 Occupancy Type:
permit is issued.
APPLICANTCERTIFICATION
I certify that I have read this application mid 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 laws 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 DAYSF OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the q
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granting of this permit. Additional) the licam understands and will comply155ued by: Date: /
8 g p )'. pp
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature, Date Z All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ ONSN'ER-BUILDER DECLARATION
Signature of Applicant: Date: /.(d
hereby affirm that I am exempt from the Contractor's License I,ew for one of
the following tion reasons: ALL ROOF COVERIe,N�. , BE CLASS"A"OR BETTER
I,as owner of the properly,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,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to IL\ZARDOUS MATERIAIS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safely Code,Sections 25505.25533.and 25534. I 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: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally.should I 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 Bay Area Air Quality Management District I
performance of the work for which this permit is issued will 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 Health&Safety Code.Sections 25505,25533.and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this O
Owner or authorized agent:
permit is issued te:
1 certify that in the performance of die work 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 ofCalifomia. If,after making this certificate of exemption,I CONSTRUCT �[FNDING AG F.NCY
become subject to the Worker's Compensation provisions of the Labor Code,1 must I hereby affirm that there is a consuuction 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
APPLICANTCERTI FICATION Lender's Address
I certify that 1 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT"S DECLARATION
costs,and expenses which may ocerue 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 Dale
1.
REROOF PERMIT APPLICATION
COMMUNITY)DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildino(okupertino.org
PROJECTADORESSOG APN• 5q_i\5 - 0-11 1 s I l/
OWNERNAME yt) I PHONE E-NIALL
MEpC+JO Q6ws-
Er ADDRESS ZI O {� TI ' STATE.LIP
�.. M J v FAN
CONTACT NAME. PHONE E-NIAIL
STREET ADDRESS5,02- S CITY.STATE.ZIP FAX
❑OKNFR ❑ OUNER-RUILDER ❑ OUNERAGENT X COYTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT (3ENGINF.F.R ❑ DEVELOPER ❑ TEN'ANT
CONTRACTOR NAME LICF.NSENCAIBER -I'Ll OR
LICENSE 'PE BUS.LIC'.•
COMPANY NAME E-MAIL FAX
SAAE
STREET ADDRESS CITY.SLATE.ZIP PHONE
sot Q OSQ CASS'Q
ARCHITECLENGINEER NA.IE LICENSE NUMBER BUS LIC.•
COMPANY NAME E-MAIL FAN
STREET ADDRESS ,/ CIT',ST.ATE.LIP PHONE
USE OF ❑ SFU or Duplex F Multi-Fam1I\' ROOF AREAL VALt;AT10A: Ae'1
STRUCT-RE'. ❑ Commercial S 5"0 j
EXISTING ROOF TYPE: ❑BLILT.L'PROOF ❑ASPIIALTSHINGLES PCVOOD SHAKES ❑WOODSHINGLES ❑01 HER I SPECIFY)
RENIOVF.:REPLACEYF.S I IF NO. PLY\\'ppD 11PLVN'D ❑OSB PITCH: ROOF
C3 N •LAYERS, 'N .. ❑ il'P 0,C
N 'ICLASS A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF /.ASPH ALT SHINGLES ❑WOOD SI LAKES ❑\NOODSHINGLES C1 OTHER IMES REPORT.
DESCRIPTION OF\CORK: 1/Z((
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By my signature below.I cenify to each of the following: I am the property owner or authorized agent to act on the prop"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 sceuiate. I agree to comply with all applicable local
ordinances and state laws relating_to building cons orize represe lig of Cupertino to enter the above-identified property for inspection purposes.
tion. I a
Signature of ApplicanUAgene Date: aO LZ
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
_ If building is associated Nvith a Home O\cner's Association.provide letter PLANCHECK TVPE ROUTING SLIP
of approval from HOA. ❑ OYER-THe COUNTER ❑ BUILDING PLAN REVIEW
Provide Planning approval to Verily I(lhCTe any reslricUOnS. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Providecopyol',Nlanufaciumr's Installation Specifications. ❑ STANDARD ❑ FIRE DEPT
Provide signed copy of Cuperiino's Tear-OfT Policy. ❑ OTHER:
Reroof.4pp_201 l.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 21095 WHITE FIR CT DATE: 09/05/2012 REVIEWED BY: MENDEZ
APN: BP#: 'VALUATION: $4,500
*PERMITTYPE: Minor Building Permit PLAN CIIECKTYPE: Re-roof
PRIMARY SFD or Duplex PENTA�fAT10N 1SFDWLROOF
USE: PERMIT TYPE:
WORK RE-ROOF 13 SQ TEAR OFF WOOD SHAKE AND INSTALL CLASS A COMP SHINGLES
SCOPE
FEE ID ROOFAREA
s.f.
iREROOFFRES 1,300
Mech. Plan Check Plumb. Plan Cheek Elec.Plan Check
blech. Permit Fee: Plumb.Permit Fee: F:lec.Pennit ree:
Odrer Meeh. Insp. Other Plumb Insp. Lj Other Elec.hup.
Hcch.Insp. ree: Plumb. lu>p.Fee: Elco, Imp.Fee:
A'OTE: This estimate does not include fees slue to other Departments(i.e. Planning, Public Warks, Fire,Sanitary Server District,School
District,etc. . These feev are based on(lie prefinyinari information available and are on&an evtitruue. Contact the Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 EI( 7/1/l1) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
Plumb.1XIech./Elec
Permit Fee: $195.00
SuploL Insp Fee
Pl utnb./A'leclr./El ec
Plunrh./A-te(!h./Elec Permit Fee:
Constriction Tac:
Administrative Fee:
Work Without Permit? r) Yes (E) No $0.00
Advanced Planning Fcew:
Travel Doc ianenlation Fees:
Strong Motion Fee: IBSE/SMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $196.50 $0.001TOTAL FEE:F$196.501
Revised: 07/01/2012