11090083 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21835 HYANNISPORT DR CONTRACTOR:YU-MEI CHEN PERMIT NO: 11090083
OWNER'S NAME: YU-MEI CHEN 21835 HYANNISPORT DR DATE ISSUED:09/13/2011
f ''NER'S PHONE: 4088068570 CUPERTINO,CA 95014-2706 PHONE NO:
Li LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REPLACE EXISTING WOOD SHAKE ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions REPLACE
Code and that my license is in full force and effect. WITH COMP SHINGLES CLASS A 25SQFT
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:$16000
permit is issued.
APPLICANT CERTIFICATION APN Number:35613046.01 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 PERMIT 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 non-point source regulations per the Cupertino Municipal Code,Section
9.18. �
Issued by: Date:
Signature Date
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 first obtaining an inspection,I agree o 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 Applicant:
I,as owner of the property,am exclusively contracting with licensed contractors to ! I
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:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS 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 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 thori7ed agent*. \ `
forthwith comply with such provisions or this permit shall be deemed revoked. Date: 0\4, 1
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 wrk'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
,ts,and expenses which may accrue against said City in consequence of the
nting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
:vith all non-poi t urce regulations p the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature ` `�� Date —I �'I Licensed Professional
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333 • buildinclacupertino.org
PROJECT ADDRESS
(+Py- �J±�7-7 APN# ;0
0 — ( Z V l/
OWNERNAME PHOw b E-MAIL
STREET gf lip 1 (��/ CITY. STATE,ZIP c1t�, p. 4"ISP
FAX
APPLICANT NAME 1 01p�� PHONE4� �0�— E- IM JL
STRE S� �,11 5 CITY,STATE,ZIP 'I 1 /_ /� kl AX
❑ OWNER t3/OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CDNTRACTOR AGENT ❑ ARCHrrFCT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME ` LICENSE NUMBER LICENSE TYPE BUS.LIC.#
COMPANY NAME V E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AIREA: VALUATION: I
STRUCTURE: ❑ Commercial
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE V4MS IF NO, PLYWOOD h" ❑ PLYWD ❑ O PTICH ROOF
❑ NO #LAYERS: TTHICKNESS: ❑ 5/8" TYPE: X '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT
DESCRIPTION OF WORK--'(0 r11^ 11 U10 Lid S 114 fj$ Y L,?A n u- LV L -5 ^
By my signature below,I certify to each of the following: Iam the pr perry owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have p ov' ed is correct. I have re the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b I " `ons 0 I au o ' e representatives of Cupertino tc enter the above-identified pproperty for inspection purposes.
Signature of ApplicanUAgent Date: J ��
SUPPLEMENTAL ORMATION REQUIRED 11801
Ifbuilding is associated with a Home Owner's Association,provide letter rE �� --�TA �
- NER
of approval from HOA. �ii � _ tR�vuy
Provide Planning approval to verify if there any restrictions. � _ '
� R7'SS = �Q3'EAIIAFG PUe17�FREP�W _
� s
Ovide
copy of Manufacturer's Installation Specifications.rro
vide signed copy of Cupertino's Tear-Off Policy.
ReroofApp_2011.doc revised 03/02/11
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228- FAX(4D8)777-3333• buildinoQcuoertino.org
CUPERTINO
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 ADDRESS�� APN I _ �// BP#
OWNER NAME \ V"I I l/ OWN DR S
DESCRIPTION OF WORK: Q ti.AL-__ ,1
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.)
mc' 1. 1 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.
�41 C-2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
A (_ 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that 1-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.
m L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
lyflu. 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.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
JJ 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.
4I`PL T. I 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
is performed under contract with a licensed general building Contractor.
� &c 8. 1 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.
Ol4'77e7Builder•Fo7-7?22010.doc revised 04114/10
C 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
MC, 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
1jj AAL 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
�'yn L, 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. if
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the 'ty may be required to be presented when the permit is issued
to verifythe roe owner's si natur
Property Owner's Signature: 1 Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
-) naeBuilderFor777 2010.doc revised 04/14/10
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 21835 hyannisport dr. DATE: 09/13/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$16,000
"PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: PERMIT TYPE:
WORK To Clear Code Enforcement Case: replace existing wood shake roof replace with comp shingles.
SCOPE
FEE ID ROOF AREA
s.f.
1 REROOFFRES 2,570
Li Li
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 prefiminatUy in ormadon available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (I'ee Xesolutior7 11-0531 1;'11) FEE QTY/FEE MISC ITEMS
Permit Fee: $364.00
Work Without Permit? Q Yes 0 No $364.00
Strom,Motion Fee: IBSEISMICR $1.60 Select an Administrative Item
Iild Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $730.60 $0.00 TOTAL FEE: $730.60
Revised: 09/02/2011