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11080194 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21731 SANTA BELLA PL CONTRACTOR:KEVIN SULLIVAN PERMIT NO: 11080194 ROOFING OWNER'S NAME: KINNUNE RICHTER F AND BARBARA 1696 VALLEY OAKS DR DATE ISSUED:08/25/2011 GILROY,CA 95020 PHONE NO:(408)842-1057 k- ER'S PHONE: 4082527158 LICENSED CONTRACTOR'S DECLARATION ECLRTION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class e' 3 ( Lic.# �n) r / MECH r- RESIDENTIAL r COMMERCIAL ? G �-'1� Date y Contractor JOB DESCRIPTION:RE-ROOF TEAR OFF SHAKE ROOF INSTALL COMP I hereby affirm that I am licensed under the provisions of Chapter 9 SHINGLES, (commencing with Section 7000)of Division 3 of the Business&Professions ADD NEW PLYWOOD CLASS A 28SQFT 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 Valuation:$11000 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: permit is issued. APPLICANT CERTIFICATION APN Number:35622022.00 Occupancy Type: 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 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, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 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. Dated Zf Issue�tsy: Signature a e 26S�61 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 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, Signature of Applicant. a 1 Business&Professions Code) I,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 I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this 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 Ow r authorized agent: 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. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION ove information is I hereby affirm that there is a construction lending agency for the performance of Wit's I certify that I have read this application and state that the ab and state laws relating for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances 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 ',mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address its,and expenses which may accrue against said City in consequence of the granting 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 I understand my plans shall be used as public records. 9.18. Signature Date Licensed Professional REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTtNO (408)777-3228• FAX(408)777-3333 • building(c cupertino.org PROJECT ADDRESS 24 I 5A A a::,La PI" 7A_PN#,3,6la 2 2- Q 2- Z_ OWNERNAME /J 2!&D E-MAIL STREET ADDRESS y � �� 'j� CITY, stm ZIP FAX APPLICANT N J j P NE E-MAII �tj it, i STREET ADDRESS 6" O _ I' �n ,STATE, ZIP ^` b-Lo F �8w ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT (,CONTRA, CTOR ❑CONTRACTOR AGENT (�❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME EQVIL LICENSE TYP BUS.LIC.# i COMPANY NAME 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 F r Duplex ❑ Multi-Family ROOF AREA: VALUATION: STRUCTURE: ❑ Commercial EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) 17 REMOVE/REPLACE YES IF NO, PLYWO h" ❑ PLYWD OSB PITCH ROOF ❑ NO #LAYERS �/ THICKNESS: ❑ 5/8" TYPE: ❑ CDX �, -12CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF HALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ElOTHER ICC-ES REPORT# DESCRIPTION OF WORK L c74 4 q Vr K 5lfi,J � 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 have provided is correct. 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 to b traction. I authorize representatives of Cupertino to enter the above-i ntified p perry for inspection purposes. Signature of Applicant/Agent �� Date: _ 1l�L/ SUPPLEMENTAL INFORMATION REQUIRED IIsY- _ If building is associated with a Home Owner's Association,provide letter P ] QWIN of approval from HOA. � _Provide Planning approval to verify if there any restrictions. - SS _ OrPl�LTIIN PLA1H3tEP�W Provide copy of Manufacturer's Installation Specifications. -now rovide signed copy of Cupertino's Tear-Off Policy. — t dos ReroofApp_2011.doc revised 03/02/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21731 santa bella pl. DATE: 08/25/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: Isi1,000 ,°PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F USE: PERMIT TYPE: WORK tear off shake roof install comp shingles, add new plywood. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 2,800 NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (Fee Resolution 11-053 E f. ';'1-%1) FEE QTY/FEE MISC ITEMS Permit Fee: $392.00 Work Without Permit? C Yes No $0.00 Strong Motion Fee: 1BSEISMICR $1.10 Select an Administrative Item Bld7 Stds Commission Fee: tBCBSC $1.00 SUBTOTALS: $394.10 $0.00 TOTAL FEE: $394.10 Revised: 07/04/2011