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12100024 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22331 SANTA PAULA AVE CONTRACTOR:WILLIAMS DAVID R AND PF,RMIT'NO: 12100024 RENS li TRUSTEE O\VNER'S NADIE: WILLIAMS DAVID R AND RENE B TRUSTEE 22331 SANTA PAULA AVE DATE ISSUED: 10/0312012 OWNER'S 1-11ONF: 4083986889 CUPERTINO.CA 95014 PIIONENO: ❑ LICENSED CONIRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT❑ PLUMB License Class Lie.q blECll r RESIDENTIAL J COMMERCIAL J Contractor Dane I hereby affirm that 1 am licensed tinder the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING SHAKE ROOFING AND INSTALL NEW (commencing with Section 7000)of Division 3 of the Business&Professions TI'T'ANIUM UNDERLAYMENT AND NEW COMPOSl{je6(1900 Code and that my license is in full force and effect. SQFI)CLASS A heretic affirm under penalty of perjury one of the folloN mg 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 Sq.Ft Floor Area: Valuation:$10000 permit is issued. AI'I'LICAN'I'CIdR'1'I1,'IGVPION APN Number:35704082.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep limitless 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 source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: �.�i9/'✓ ��G� Date: /,0 -✓?-Ig Signature Date ❑ OWNEWBUILDFR DECLARATION RE-ROOFS: I here[)),affirm that.I am exempt from the Contractor's License Lav for tine of All roofs shall be inspected prior to any roofing material being installed.if a roof is the following nyo reasons: installed Without first obtaining an inspection,I'agree to remove all new materials for I,as owner of the property,or my employees With wages as their sole compensation, inspection. will do the work,mid the structure isnot intended or offered for sale(Sec.7044, Business S Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business R Professions Code). ALL ROOF COVERINGS TO IIF CLASS"A"OR BETTER hereby affirm under penalty of perjury one of the follmring three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's ILVLAIIDOIIS\LVI'F:RIAI S DISCLOSURE 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 Ilealth S Safety Code.Sections 25505.25533,and 25534. I wi11 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 Ilealth S Section 3700 of the Labor Code,for the performance of the Work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Ray Arca Air Quality Management District I%%ill I ceni(y•that in the performance of die Work for which this permit is issued.I shall 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 the Worker's Ilealth S Safely Co F.Sections 2.5505.25533,and 25534. Compensation laws of California. If,after making This certificate ofexemption,I become subject to We Worker's Compensation provisions of the Labor Code,I must Ownernr a`ni 'd agent: forthwith comply with such provisions or this permit shall be deemed rooked. Date: APPI,ICA,N I'CF.RT'IFICA'I'ION CONSTRUCTION LENDING AGENC\' 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 lases relating for which this permit is issued(Sec.3097,Civ C.) to building construction,mrd hereby authorize representatives of this city to 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 casts,and expenses which may accrue against said City in consequence ofthe granting oflhis permit.Additionally,the applicmn understands and will comply ARCIII'1'ECI"S DECLAMATION With all non-point source reg: tions per the Cupertino Municipal Code.Section 9.18. Z — I understand my phos shall be used as public records. Signature Dater Y' — /y Licensed Professional OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO. CA 95014-3255 CUPERTINO (408)777-3228• FAX (408)777-3333 • building6cuoenino.ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESSZZ 3 I P {^�I�/// APN BP# 3 I P I "i OWNERNAMEOWNERADDRESS r� t�llLlf4 c �3 i SswTa Qr� ,—N f�c• c ca�� Sol DESCRIPTION OF WORK: P-4 We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for t e construction and are not hiring a licensed Contractor to assume this responsibility. . 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in.California and to list their license numbers on permits and contracts. .4:��5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. _ understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. fir•/ 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work pis performed under contract with a licensed general building Contractor. ,!�'p8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OmnerBuilderForm 2010.doc revised 04/74/10 IZ(o (--� -2- REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX (408)777-3333• buildinct(lcuoertino.org / PROJECT ADDRESS . SY+,TA- PAvj-, Y1Vf.• APN 0 OWNER NAME , J`-P" -4 PHON 1 EAIAIL` (1 W 1 1-L-A IQ-r-N S �1 O8 •-3x'18 b O\J4F re (Lmn C•y.rc t ,... STREET ADDRESS (� CITY, STATE,ZIP FAX 2Z3� ( -,P"rA Pf+vt.A % INTI CONTACT NAME IPSPHOT V-6 .aye Wp ( E-MAIL 1 Gtr} W A.41 `1 O t STREET ADDRESS S,Q M C- CITY.STATE.ZIP FAX ❑OWNER �(OWNE BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ AitcmrcQ ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSETYPE BUS.LILY COMPANY NAME E-SIAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC n CO\IFANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF 9 SFD or DLIPICX ❑ f\Itdu-Iralnll) ROOF AREA: VALUATION; STRUCTURE ❑ Commercial � S'6 S4Tvi+-R£S /z�? EXISTING ROOF TYPE'r ❑BUILT-UPROOF ❑ASPHALTSHINGLES L�\\'00D SHAKES ❑WOODSHINGLES ❑OTHER(SPECIM REMOVEIREPLACE IOYES IF NO. PLYWOOD ❑ 'A- ❑ PLYWD ❑ OSB PITCH: ROOF ❑ LAYERS YER T 1 K GS 18" TYPE. CDX ')? LASS' A PROPOSEDROOFTYPE: ❑BUILT-UPROOF IWASPHALTSHINGLES 13 WOOD SHAKES ❑WOOD SHINGLES 13 OTHER IMES REPORT DESCRIPTION OF WORK: �fr- ovE. Sht(kk� IN S!-!�'L-L SO �� G4.2TRIT��1� Co.\^ Qos irlol.� Slr+,-ao-r_£ �4�clsrl1,t1Na- -f/g G.oK fly w00p - LJJ�.a {c las � V 1`�xvtviM �flEA1 l..En,i- By my signature below,I certify to each of the following'I an,the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information I have provided is con have read the Description o(R'ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil�ng c t t n. I authoclze representatives of Cupenino to enter the above-identif ed pr ny for inspection purposes. Signature of Applicant/Agent: � Date: Io 3 )Z SUPPLEMENTAL INFORMATION REQUIRED - OFFICE USE ONIA _If building is associated with a I Imre Owners Association,provide letter - -!FILN.CHECK:TYPE. cJ_ _ ROUTING SLIP _ of approval from 110A. OVER-THF.-COUNTER. T BUILDING PLAN REVIEW Provide Planning approval to veri rV if there any restrictions. EXPRESS •NU PLANNING TERN REVIEW,_Provide copy of Manufacturer's Installation Specifications. ❑, STANDARD ',O` FIRE DEPT Provide signed cop) of Cuper ino's'fear-OE Policy. ReroofApp_101 I.doc revised 03116111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 22331 Santa Paula Ave DATE: 10/03/2012 REVIEWED BY: Sean APN:36�7_ 0Lf - pRA I BPq: 'VALUATION: $10,000 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIDU+.RI' PERTANIATION USE: SFD or Duplex PFRMITTYPEi 1SFDWLR00 WORK Remove existing shake roofing and install new titanium underla ment and new composition 1900 s SCOPE I ft). FEEID ROOF AREA 5.f. 1REROOFFRES 1,900 Alech. Plan Check Plumb. Plan Check Flee. Plan Check Alech. Permit Fee: Plumb. Perini!Fee: Pile[.Permit Fee: Other Alech. Insp. Other Plumb Insp. Oilier rice.Imp. Me&buy.Fee: Plumb. hup. ree: Elec.Lap.Fee: NOTE: This estinmte does not include jeer clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School 'District,etc. . These ees are hared oit the prelitninan information available and are only an estimate. Contact the De 1 or atltln7 info. FEE ITEMS (Fee Resolution 11-053 Elf 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Tee Plumb.11lech./Elec Permit Fee: $285.00 Suppl. lisp Fee Plumb.64/ech.lElec Plunib./Alech./Elec Permit Fee: Constrnctint Tax: Administrative Fee: Work Without Permit? O Yes Q No $0.00 Advance[(Planning Fees: Travel Documentation Feces: S110116 Motion Fee: IBSF.ISAIICR $1.00 Select an Administrative Item 131da Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $287.001 $0.001 TOTAL FEE: $287.00 Revised: 1 0/0 112 01 2