13020105 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10465 DEMPSTER AVE CONTRACTOR:R 1 BEAN ROOFING PERMIT NO: 13020105
OWNER'S NAME: PROKEY NORMAN T AND BETTY L 6355 COTTLE RD DATE ISSUED:0220/2013
OWNER'S PHONE: 4084271417 SAN JOSE,CA 95123 PHONE NO:(408)358-4028
❑
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# / 5-03 C) TEAR OFF(E)WOOD SHAKE,INSTALL 30#FELT,50 YR
PREMIUM COMP 2(e
Contractor Date Z �G.V'�3
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect
I 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. Sq.Ft Floor Area: Valuation:$10000
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 APN Number:32648011.00 Occupancy Type:
permit is issued. -
APPLICANT 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 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 DAY 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 Iss Date: Z (�
granting of this permit. Additionally,theapplicant understands and will comply
with all non-point source regulations per the Cupertino Municipal lode,Section
9.18: -
-..�^_r RE-ROOFS:
Signature Date !w / 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 Applicant: ia'b141V,1Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: . ALL ROOF COV RINGS TO BE 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(Sm.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
concoct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. Twill
1 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 I store or handle hazardous
I 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,Secti s 25505 25533,and 25534. t�
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dste: 2b 1
permit is issued.
I certify that in the performance of the 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I 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. works for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTWCATION Leader's Address -
I certify that I have read thisapplication 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 purpose's.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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: 10465 DEMPSTER AVE DATE: 02/20/2013 REVIEWED BY: MELISSA
APN: 326 48 011 BP#: I 'VALUATION: $10,000
*PERMIT.TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY I PENTAMATION
USE: SFD Or Duplex PERMITTYPE: 1SFDWLROOF
WORK TEAR OFF E WOOD SHAKE INSTALL 30#FELT 50 YR PREMIUM COMP
SCOPE
70
HE
ABech. Plan Check Plumb. Plan Check Elec. Plan Check
:Llech. Permit Fee: Plumb. Pee,mit Fee: Elec. Permit Fee:
Other A1ech. Insp. Other Plumb 7n.tp. Other Elec.Insp.
41e.ch.Insp. Fee: Plumb. hap. Pee: /,,lee.Insp. Pec.
NOTE:This estimate does not includefees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District'School
Dstrict eta). Thesefees are based on the prefindn in orn don available and are only an estimate. Contact the Dent for addu'l info.
FEE ITEMS(Fee Resolution 11-053 Eft' 7111121 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 ff,660 s.f. Re roof
Suppl.PC Fee: Q Reg. Q OT0.0 hrs $0.00 $390.00 IREROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Fee: O
Work Without Permit? O Yes Q No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fees: Building or Structure O
Strong Motion Fee: IBSEISMICR $1.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
t $2.00 $390.00 'q' p '.xx TOTAL FEES;'
Rr , t � $392.00
Revised: 01/01/2013
REROOF PERMIT APPLICATION \04
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION (Lo
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ^ O
CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcuoertino.ora \,V�
PROJECT ADDRESS L4(1C APNk .7 /' �J /
OWNERNAAaa \J O�/ PHOn. _I I27— ` Ip &MAIL 1
STREET ADDRESS CITY, STATE,Z `-� /�' FAX
t�A
CONTACT NAMEPHO I Llb6E-MAIL
IK7r -hp 401 (a ASTREET ADDRESS CITY,STATE, /� FAX
❑OWNER ❑ OWNER-BURDER ❑ OWNERAGENT CONTRACTOR ❑CONiRACrORAGENTT ❑ ARCm1ECf ❑ENaNEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME1 l` LICENSE LICINS TYP BUS.LIC.k
COMPANYNAME v 1 &MAIL - FAX
^
STREET ADDRES �C uffijCITY,STA ZIPi P ,O
ARCHITECT/ENGrNEER NAMES LICENSENUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex Multi-Family. ROOF AREA: VALUATION:
Os
STRUCTURE: ❑ Commercial
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOODS S ❑WOOD SHINGLES Z OTHER(SPECIE
RFIAOVE/REPLACE YFS IF NO, PLYWOOD K" ❑ PLYWD ❑OSB PRCH: ROOF
N MLA ❑ B" E' ❑ DX ,12 LASS: A.
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF XSPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT k
DESCRIPTION OF WORK'.
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//t V ✓c
1 tib lir' rAhIM
By my signature below,I certify to each of the following: Iain the property owner or authorized 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 actuate. I agree to comply with all applicable local
ordinances and sate laws relating 7d' co coon. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplicam/Agent WA&2 Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE DSE ONLY
_If building is associated With a Home OWner's Association,provide letter PLANCHEcKTTTE tint NGSLIP
of approval from HOA. ❑ OVER-TTD}COUNTER' ❑ BUILDING PLAN REVIEW
_Provide Planning approval to verify if there any restrictions. ❑)EXPRESS ❑-PLANNING PLAN REVIEW
_Provide copy of Manufacturers Installation Specifications. ❑ STANDAR ❑ FIRE DEPT
Provide signed copy of Cupertino s Tear-Off Policy. ❑ OTHER:
ReroofApp_201 Ldoc revised 03116/11