12090213 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS; 21080WIiITE FIR CT CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 12090213
OWNER'S NAME: GOULARTE RONALD A AND LOGAN JO ANNE PO ROX 1668 DATE ISSUED:09252012
OWNER'S PIIONE: 4085106937 SAN JOSE,CA 95109 11IIONE NO:(408)278-0330
LICENSED CONIRACI'OR''S DECLARATION' BUILDING PERMIT INFO: BLDG C ELECT C PLUMB[,
License Class C— 3 ( Lic.q r_l� a(DOi
D1EC11 r RESIDENTIAL COMMERCIAL r
Contractor F—Sr?_t I r1 C • Date 2 '"2 S- (2
I hereb)'affirm that I nor licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF EXISTING WOOD SHAKE ROOF.INSTALL 12"
(commencing with Section 7000)of Division 3 of the Business& Professions COX
Code and that my license is in full force and effect. PLYWOOD&30k FI?LT UNDERLAYMENT.INSTALL 13 SQ CLASS
A CERTAINTEED PRESIDENTIAL CONIP
1 hereby affirm under penalty of 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.
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
permit is issued. Sq.F1 Floor Area: Valuation:54500
APPLICANT CERT'I FIC\T'ION
I certify that I have read this application and state that the above information is APN Number:35905098.00 Occupancy T ype:
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
upon the above mentioned property for inspection purposes, (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of
granting of this permit. Additionally,the applicant underslandslaid will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature — Date 9- Zs'�2• Issued by: %5r, Date:
❑ ON'NEI- UILDER DECLARATION
1 I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any tooling material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code) f
I,as owner of the property,am exclusively contracting with licensed contractors to Signature ol'Applicant:. Date:
construct the project(Scc.7044,Business&Professions Code).
hereby affirm under penalty of perjuy one of the fnllmving three ALL ROOF COVET ,•GSTO BE CLASS"A"OR BETTER
declarations: _
I have and will maintain a Certificate of Consent to self-insure for Worker's IIA'J,ARDOUS NL\T'ERIAIS DISCLOSURE.
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety'Code,Section 25532(a)should I store or handle hazardous material.
permit is issued Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Workers maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Ilealth&Safety Code.Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must ���
forthwith comply with such provisions or this permit shall be deemed revoked. O"rte r au aU agent: 9-ZS�/2
Date
APPLIC\NTCERT'I FIC TION CONSTRIICI'ION LENDING AGENCY
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordin:ices mid state lases relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this citto enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said Cit'in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ARCI I I'I'FCI"SDECL,\RA'T'ION
I understand my plans shall be used a public records.
Signature Date -
hittnscJ Professional
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
(408)777-3228- FAX(408)777-3333-buildina(a)cupertino.ora
CUPERTINO l
PROJECT ADDRESS 21oaO aPN
�- I L-35 I — o !5—
cqR
OWNERNAME ; PHONE E-NIAIL
STREET'ADDRESS�J IOpO Cll ' 11,4TE.Zl; HS
CONTACT NAME PHONE E-?IAIL
y -2,
STREET ADDRESS SO2 S+. CIT) STATE.ZIP/ Fd\
11.1na I San J
El OWNER ❑ O\\NER-BUILDER ❑ ON'NERAGEENT 1./CO\TR>CTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME I LICENSENCMBER I LICF.NSET"PE aL-S.LIC.-
y z OR
COMPANY NAME I E-MAIL FAX
STREET ADDRESS CIT'.STATE.ZIPPHONE
S'07- I q oSe III C -Z 8'O
ARCHITECT:ENGINEER NAME LICENSE NUMBER BUS.LIC-
COMPAUYNA.ME E-MAIL FAX
STREET ADDRFSS I CIT".STATE./.IP PHONE
USE OF ❑ SFO or Duplex )C Multi-Family ROOF AREA; Jo VALCATION; ty —p9—
STRUCTURE; ❑ Commercial �ay/ j S W L S(�
ESISTINGROOr TYPE: ❑BUILT-L'PROOF C3ASPI IALT SHINGLES XWOOD SHAKES ❑WOODSHINGLES ❑01'HER(SPECIFY)
REMOa'F.:REPLACE MYES IFNO. PLYWOOD (:' ❑ Plt'W'D ❑ OSB PITCH; ROOF
❑ N a AYER I ANESS == i8- ll'PE- CA—:12 CLASS A
PROPOSED ROOF TYPE; ❑BCILT-UP ROOF iKaSPHALT SHINGLES ❑\cpOU SIIAriE] ❑\s OOD SHINGLES L'OTHER (MES REPORT J
DFSCRIPTION OF WORT:: 1
454 e><is+;n� +.good Glnalie rood' _ 2ns-tIail Ma" Cox
Ce4a:iakeed QreSide�;a.l Conan s6wi es color C��n�n. Gray
By me signature beloo'.I certify to each of the following: I am the property oacner or authorized agent to act on the propemouner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Mork and vetifc it is accurate. I agree to comply with all applicable local
ordinances and state lays relating to building cons^ tion. I a OnZe reprec tiY of Cupertino to enter the above-identified property for inspection purposes.
Signature ofnpplieantlAgem: Dace: ao 12
. SUPPLENIENTALINFORMATION REQUIRED OFFICE USE ONLY
_ If building is associated with a Home OWner's Association.provide letter PLAN CHECK TYPE ROUTING SLIP
of approval from HOA. ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
_Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLAN:NI6C PLAN RE\'IEN'
Provide copy'of(btanufacturer's Installation Specifications. ❑ STANDARD ❑ FIREDEPT
Provide signed copy of Cupenino's Tear-Off Policy. ❑ OTHER:
ReroojApp_101 Ldoc revised 03116111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 2,(,-:> tU N- (t DATE: REVIEWED BY:
71M4 APN: BP#: I *VALUATION: 1$4,500
*PERMITTYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION 1SFDWLROOF
USE: I I PERMIT TYPE:
NVORK TEAR OFF EXISTING WOOD SHAKE ROOF.INSTALL 1/2" CDX PLYWOOD& 30# FELT
SCOPE UNDERLAYMENT.INSTALL 13 SOFT CLASS A CERTAINTEED PRESIDENTIAL COMP o
FEEID ROOFAREA
s.f.
1REROOFFRES 1,300
Meeh.Plan Cheek Plumb. Plan Check Elec.P/mt Check
Much. PLrnfif Fee: Plumb.Permit Fee: Elec. Permit Fee:
Other Hech.trip. other Plumb b'sp. Olhew Elm htsp.
E17-
'ilrech.Insp. Fee: Plumb.Insp.Fee: Elee.Ince. Fee:
NOTE: This estinmte does not include fees due to other Departments(i.e.Planning,Public Narks, Fire,Saninny Sewer District,School
District,etc). These fees are based an the prelininary in ornmtion available and are mdi'an estimate. Contact the De t or addn't info.
FEE ITEMS (Fee Resolution/1-053 EJf 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl.PC Fee
Phanh.r'tllech..E1ec
Permit Fee: $195.00
Suppl. Insp Fee
Phnnb.iiNech.iElec
Plumh_"44ech.:F7ec Permit Fee:
C roistructicni Tax:
Administrative Fee:
Work Without Permit? O Yes (E) No $0.00
Advanced Planning Fees:
Travel Documenhrrion Fees:
Strong Motion fee: IBSEISABCR $0.50 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOT LS., $196.501 $0.001 .
TOTILFEE: $196.50
Revised: 07/012012