10110103 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10642 RANDY LN CONTRACTOR:ROSE ANDREWS PERMIT NO: 10 110 103
OWNER'S NAME: ROSE ANDREWS 10642 RANDY LN DATE ISSUED: 11/16/2010
WNER'S PHONE: 4082520242 CUPERTINO,CA 95014-2055 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# RE-ROOF 20 SQ TEAR OFF WOOD SHAKES,7/16 OSB 30#
FELT 30 YR COMP CLASS A
Contractor Date
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:$6800
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:31602066.00 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 F 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 D FROM LAST CALLED INSPE TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the l
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
FS.
Signature Date All roofs shall be inspected p i r to y ro mg m erial being installed.If a roof is
installed without first obtai ng an spe ion,I a ee to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL O GS 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(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licen d tractors to RDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). a read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the fo a maintain compliance wit a ertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code, ection 25 32(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additional) ,should I e equipment or devices which emit hazardous.-
by ,
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as efined t Bay Area Air Quality Mana Bistr t I
performance of the work for which this permit is issued. will maintain compI nce with Cupertino Muni ' aF e,CChaaptter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety ode, tion 255 ;Muni
25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or a t Dat
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
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. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all ci y and county ordinances and state laws relating
to building constructio , d her authorize representatives of this city to enter
upon the above me coned properAfor inspection purposes.(We)agree to sa ARCHITECT'S DECLARATION
ndemnify and k p harmless th ity of Cupertino against liabilitie gments,
ts,and exp ses which may ccrue against said City in quence of the 1 understand my plans shall be used as public records.
a.anting of th' permit.Addif nally,the applicant rstands and will comply
with all of
oint source r u atio F tlt ertino M ip Code,SeCtjon Licensed Professional
9.18.
Signature D t
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10642 randy lane. DATE: 11/16/2010 REVIEWED BY:
APN: BP#: *VALUATION: 1$6,800
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
lex ( !1. PENTAMATION 1 SFDWLROOF
USE: P 1°r �( k " �� ?. PERMIT TYPE:
PRIMARY SFD or Du
WORK
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 2,000
llc, rt. !1,rr Ch,f
k"
�ffr73'f'.1 l is"tl l, 11f.`3
I
NOTE: Thesefees are based on the prelinddnary in ormation available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Reso/utiol7 09-051 E[f. lilr)) FEEQTY/FEE MISC ITEMS
Plan C'hc(A Fe=c':
.SiiPIV, 1'( `I C
f'Trita�fa.%:tl c li..%I Ic c:Plan
Permit Fee: $260.00
phallb-,Ilc ch. C'rrii Fee:
l'/i�ritfi.;:dccli.;T 1c c�Periliit Fc°c:
F-1
r.,on,writcliol'7 1 tIx
,,Ic:oilsiicarl Rcvie= i,I-ec.
Work Without Permit? 0 Yes E) No $0.00
P!anrlhlo Fuc"s:
71-avel L)c���tiirr rrfutic?ri 1'c�c°s:
Strong Motion Fee: IBSEISMICR $0.68 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $261.68 $0.00 TOTAL FEE: $261.68
Revised: 11/08/2010
� LAAA.A AJQ-V CC4—A.
-ka
S,,,.-
Aov
; 10,0
eY��
M.indoor Air Quality and Finishes
1 IAQ/Hsalth pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
.3•4J"LDW*VPC Adiom 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.SOW 40 fmajod fla—ft-b"d 11K W 4IAQ/Health.pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource ptsy=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
1 i 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
U99 gap*RW40W&eF7oonrWS 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts Ayes 0
5.Use Exposed Concrete as Finished Fioor 4 Resource pts y=yes 0
G.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available-1 1 140F 130 57
Total Points Project Received: 01 0 0
G:datalprogs! Wdldn@gi id ' s/remo elers/greenpointsfina121204protnted
Ila Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CO TRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: L I v I v
OWNER'S NAME: PHONE#00
GENERAL CONTRAC O : 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 INS CTION(S) WILL BE SCHEDULED UNTIL E
GENERAL CONTRACTOR AND ALL SUBCONT TO HAVE OBTAINED A CITY OF CUP RTI O
BUSINESS LICENSE.
I am g any subcontractors:
ignature 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 Roc
Tile
ner/Contractor Signature Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333- buildina(a�cuoeriino.org
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 BP#
OWN OR NAME OWNAKADDRESS
DESCRIPTION OF WORK:
We are providing you with an Owner-Build 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
(DIRECTNS:Please read and initial each statement below to signify you understand or verify this information.)
1. 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
prov' a coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
in
r nce coverage for injuries to workers on my property.
understand building permits are not required to be signed by property owners unless they are responsible for
e onstruction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an"Owner-Builder' I am the responsible party of record on the permit. I understand that I may
pro ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
na instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
nu b r on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
t ;1,
alue of my construction is at least five hundred dollars($500), including labor and materials, I may be
cdered 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
federal government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
Arneloyment compensation for each"employee." I also understand my failure to abide by these laws may subject
serious financial risk.
I understand under California Contractors'State License Law, an Owner-Builder who builds single-family
reside i structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
lie ed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
i ormed under contract with a licensed general building Contractor.
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. _
OwnerBuilderForm 2010.doc revised 04114/10
i
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
Licerhe Board(CSLB)at 1-800-321-CSL13 (2752)or www.csib.ca.gov for more information about licensed
contffictors.
fba
0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that
e party legally and financially responsible for proposed construction activity at the site address listed above.
1. 1 agree that,as the party legally and financially responsible for this proposed construction activity, I will abide
applicable laws and requirements that govern Owner-Builders as well as employers.
2. 1 agree to notify the issuer of this form immediately of any additions',deletions,or changes to any of the
ation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
ntract 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 c -Qp/ife the following construction lending agency information.)
I hereby affirm th th construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)'
Lender Name: Lender Address:
Before a builds permit can be issued this rm ust be completed and signed by the property owner and
returned to th agency responsible for iss ng th ermit. Note:A copy of the property owner's driver's license, -
form notarization, or other verification accept ble to city may be required to be presented whe the ermif i¢ sed
to verify the property owner's sign ture. C/
Property Owner's Signature: Dat
---------------------------------------------------------------------------------------------------------------------------------------------
(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 filelthe documents necessary to obtain an
Owner-Builder Permit for my project. _ /
Scope of Construction Project(or Description of Work): iF Vf�F «
Project Location or Address: L-' a•.^--1a-,„U
Name of Authorized Agent: 4V C—C14 r Tel No
Address of Authorized Agent:
declare under penalty of perjuryt am the,property owner for the address listed above and I personally filled out the
above information and certify it ccur y. N e:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the may a re aired to be presented when the permit is issued to erify he property owner's
signature. 'G
Property Owner's Signa re: Date:
OwnerBuilderForn: 2010.doc revised 04114/10
"Y OF
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION U
APN# 00 Date:
Building Address:
Owner's Name: � Phone #: �
HOA: Yes El No If yes, provide letter from HOA �J
Contr tor: Phone
Fax
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: . Proposed:
❑ Built-Up Roof ❑ Built-U rnof
❑ A§phattShingles ❑ ,Ahalt Shingles
ood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.C.E.S. Report#
❑ To be Removed ❑ Provide Mfg. Installation Specs.
Job Des ipti : .--7/�
h
Residential Commercial
Green Building: Please complete relevant portion of the Confirmed with--Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, i e sheet index.
Valuatio
I Have Read, Underst and Wi Co ply with Cupertino's Tear-Off Policy:
Signaft
Revised 02/05/09
CITY OF CUPERTINO BUILDING P RMIT
BUILDING ADDRESS: 11640 REGNART CANYON DR CONTRACTOR:MT2 TELECOM,LLP PERMIT NO: 10100120
OWNER'S NAME: JANET DECARLI 3780 COMMERCE DR DATE ISSUED: 11/242010
OWNER'S PHONE: 4082572100 W SACRAMENTO,CA 195691 PHONE NO:(916)376-8555
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: IIESIDENTIAL 13 COMMERCIAL
License Class 14 Lic.# 61,2 1JOD 1 INSTALL WIRELESS FACILITY,INSTALL NEW(3)
Contractor /-Ir ,/t 7ZXCec�c+ PANELS
Date #I-qq110 ATNENNAS AND(4)NEW MICROWAVE DISHES AND
1 hereby affirm that I am licensed under the provisions of Chapter 9 WIRELESS
(commencing with Section 7000)of Division 3 of the Business&Professions EQUIPMENT ON 113ROUND.
Code and that my license is in full force and effect.
1 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:$35000
1 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
is APN Number:36633006100 Occupancy Type:
permit is issued. ��
APPLICANT CERTIFICATION
I certify that 1 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 18d 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 DAYS FROM LAST 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 the1/1'-2granting of this permit. Additionally,the applicant understands and will comply
Issued --' Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
N RE-ROOFS:
Signature t�C/Xt�i 1� -t.P;�7�! i/�_ Date % 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
❑ OWNER-BUILDER DECLARATION inspection.
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct 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. 1 will
I 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 1 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
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized ageult: -(G-'t/iZ Cer i1L�h/hCJ�ate: /I - {-
1 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
Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY
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, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.1 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 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 1 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