11090080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21941 COLUMBUS AVE CONTRACTOR:XTERIA CONSTRUCTION PERMIT NO: 11090080
OWNER'S NAME: CHOW MAROLYN O PO BOX 5460 DATE ISSUED:09/12/2011
r""NER'S PHONE: 4082577883 SAN JOSE,CA 95150 PHONE NO:(408)289-5353
Ci LLICENSED CONTRACTOR'S^DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class 6__S9 Lic.# C��9
��.� � MECH RESIDENTIAL COMMERCIAL
Contractor J( ///� �PS� C/ �U�te ( '�Z'"��
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REPLACE SHAKE ROOF&INSTALL COMP
(commencing with Section 7000)of Division 3 of the Business&Professions SHINGLES
CLASS A 25SQFT
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.
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 Sq.Ft Floor Area: Valuation:$11400
permit is issued.
APPLICANT CERTIFICATION APN Number:35614035.00 Occupancy Type:
I certify that I 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 PENT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless 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 - urce regulations per the Cupertino Municipal Code,Section
9.18. �12�
�� Date:
Signa re Date Issued b
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without firstabLW4jnUK 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,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Ap ican. Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will 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 Health&
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 Bay Area Air Quality Management District I will
I certify that in the performance of the 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 Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner riz d
Date:
forthwith comply with such provisions or this permit shall be deemed revoked. )
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
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 laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and 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
°s,and expenses which may accrue against said City in consequence of the
.ting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35614035 . 00
DATE ISSUED. . . . . . . : 09/12/2011
RECEIPT #. . . . . . . . . : BS000014733
REFERENCE ID # . . . : 11090080
SITE ADDRESS . . . . . : 21941 COLUMBUS AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CHOW MAROLYN O
ADDRESS 21941 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4714
RECEIVED FROM . . . . : PAC-NET INDUSTRIES,
CONTRACTOR . . . . . . . : PHILLIP ULLIO LIC # 22346
COMPANY . . . . . . . . . . : XTERIA CONSTRUCTION
ADDRESS . . . . . . . . . . : PO BOX 5460
CITY/STATE/ZIP . . . : SAN JOSE, CA 95150
TELEPHONE . . . . . . . . : (408) 289-5353
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 11,400 .00 1. 00 0 . 00 1 . 00 0. 00
1BSEISMICR VALUATION 11,400. 00 1. 14 0 . 00 1.14 0. 00
1REROOFRES SQ FEET 25 . 00 350 . 00 0. 00 350 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 352 . 14 0. 00 352 .14 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 352 . 14 #1558
---------------
TOTAL RECEIPT 352 . 14
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
309 EXTERIOR LATH 311 SCRATCH COAT
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21941 Columbus ave. DATE: 09/12/2011 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: 1$11,400
'PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION 1 SFDWLROOF
USE: PERMIT TYPE:
WORK replace shake roof and install comp shingles.
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 2,500
Li _j
NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.).
Thesefees are based on the preliminary in ormadon available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resohrtion 11-053 El. 7Z'11) FEE QTY/FEE MISC ITEMS
Permit Fee: $350.00
Work Without Permit? Q Yes Q No $0.00
i
Strom Motion Fee: IBSEISMICR $1.14 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $352.14 $0.00 TOTAL FEE: $352.14
Revised: 09/02/2011
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 ' FAX(408)777-3333 • buildingecupertino.org
PROTECT ADDRESSJ J 9 q) O I�M APN# 14 03
43
OWNER NAME /�� +•� ` SOI , l t .�S�' 7�-y3 E-MAIL
STREET ADDRESS / S/`,f�/� I vV CITY. STATE,ZIP U ��jr� y' N FA7C
APPLICANT NAME �r, ^ (` � C .� PHONE E-MAIL
STREET ADDRESS L-SVG•J�� V C. Crrl'STATE,ZIP `r'� / Jr/ FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT XONTFLACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMEPA , I / i LIGE NUMBS LICENSE TYPE BUSS.LIC.# r�
COMPANY NAME �r s• �`S/`�G'•Cf U E M I L. ��/I /�+ f� l FA
/1S �J .
STREET ADDRESS / Mer., n/4 � r CITY,STATE,ZIP �1� PHONE
ARCHITECT/ENGINEER NAME (� LICENSE NUMBER / BUS.LIC.
COMPANY NAME E-MAIL (O FAX QC J
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or Duplex El Multi-Family ROOF AREA: VALUATTO 0 Q
STRUCTURE: ❑ Commercial / 1-100 '
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES FOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE IF NO, TPLYWOOD ❑ h" ❑ PLYWD OSB PTrCH ROOF
❑ No #LAYERS: THICKNESS: ❑ 5/8" TYPE: ❑ CDX '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF PSkSPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT#
DESCRIPTION OF WORK:'PemO tV e-, Rep
f n c,(o- Roof--.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I ha i orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating building tru 'on. I ut fives of Cupertino tc enter the above-iden d pro ert••for insspe tion purposes.
Signature of Applicant/Agent Date: /
SUPPLEMENTAL INFORMA REQUIRED
_If building is associated with a Home Owner's Association,provide letter
of approval from HOA. utR � , _ v
�— I
Provide Planning approval to verify if there any restrictions. =xvR�s I�smR• pr� ��w
_Pro 'de copy of Manufacturer's Installation Specifications.
Provide signed copy of Cupertino's Tear-Off Policy.
ReroofApp_2011.doc revised 03/02/11
REROOF TEAR-OFF POLICY
is, COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228- FAX(408)777-3333-building(&-cupertino.ong
PROJECT ADDRESS I /_aOmicts
APN#
OWNER NAME I - ` PHO➢dE)�✓ E-MAIL
STREET ADDRESS CITY, STATE,ZIr y�i�� FAX
n El P
CONTRACTOR NA7Qr •� �NS �ruri�/. ,JCENSR� LICENSE TYPE BUS.LIC.#
Zo
/ 10
COMPANY NAME '` E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
I UNDERSTAND AND AGREE TO THE FOLLOWING:
1. The re-roof project shall comply with all applicable provisions of the 2010 California Codes.
2. An inspection request can be scheduled up to the day before the inspection date. Please call (408)777-
3228 from 7:30 - 3:30pm (Mon-Thurs) or 7:30 - 2:30pm (Friday) to schedule the next day inspection.
For Tear-Off and Nailing Inspections, you must also call on the day of the inspection only after that
phase of the work is completed. The building inspector will be available within one hour. Progress
and Final Inspections will be given a two hour window.
3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked-down or removed prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the
building inspector. Any roofing which is applied without first obtaining an approved inspection will
require the removal of all new material down to the sheathing so a proper inspection can be performed.
6. Progress Inspection is required when approximately 50% of roof covering is installed.
7. A Final Inspection and approval shall be obtained from the building inspector when the re-roofing is
completed. To receive a final sign-off, the following items will be verified:
a. Flat roofs shall have a minimum of'/" per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre-manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
8. NOTE: If you call for a tear-off or plywood nailing inspection and the work is not complete, you will be
charged a re-inspection fee of$126.00. The re-inspection fee shall be paid before another inspection
can be scheduled.
By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act on the
property owner's behalf. I understand and agree to comply with the re-roof policy stated above. I also understand that
smoke detectors and carbon Innox, et ct are required to be installed in accordance with Sections 8314 and R315 of
the 2010 California Residential ode. //
Signature of Applicant/Agent: Date: 2,
ReroofPolicy_201 6oc revised 02/16/11
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: �/ of S PERMIT# �
OWNER'S NAME: 1y r1' C yo A J PHONE# qg - 3 —
GENERAL CONTRACTOR: A /'wG t•p.1J BUSINESS LICENSE #
ADDRESS, CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL CTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. =k
I am not using any subcontractors:
1-1 ture Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
n ntractor Signature Date