10090185 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10560 GLENVIEW AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10090185
DATE ISSUED:09/20/2010
OWNER'S NAME: LORI NIELSON
PHONE NO:
NER'S PHONE: 4087295653
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT[_ PLUMB
license Classc._— Lic.# 7 5�oy MECH r RESIDENTIAL r— COMMERCIAL r
Contractor o F >aar, i.1A, Date ^Q b d
JOB DESCRIPTION:RE-ROOF TEAR OFF EXISTING SHAKE ROOF INSTALL 1/2"
I hereby affirm that I am licensed under tiie provisions of Chapter 9 OSB INSTALL 40YR COMP CLASS A 25SQ
(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.
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:$8500
permit is issued.
APPLICANT CERTIFICATION APN Number:36913059.00 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 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. Date:�
/r Issued by! 7Signature�tl-1�1��'� Date "�0��D
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, Date:
Business&Professions Code) Signature of Applicant
I,as owner of the property,am exclusively contracting with licensed contractors to _-7
construct the project(Sec.7044,Business&Professions Code). J 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 n 370ermit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 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&
Safety Code,Section 25532(a)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 Owe or authorized a,g n
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: � d
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
'�mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
,and expenses which may accrue against said City in consequence of the
g,anting 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
M.Indoor Air Quality and Finishes
1.Use LowRslo-VbC Paint 1 IAQ/Hsalth pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y--yes D
3.Use LowffiloVOG Adhesives 31AQ/Health pts y=yes 0
4,Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes D
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.$BdA dard,or#ADl= 41AQ/Health pts y=yes D
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
1 1
10.Install Whole House Vacuum System 3[AQ/Health pts y=yes I I D
1 1 0
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2 Use Rapidly fla aewable Flooring 1Al4ter Os 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 y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
r
Total Points Available:1 1 1401 1301 57
Total Points Project Received: C � 0 0 0
G:data/progs/gr;enbuildingguidelinWremodelers/greenpointsfinal21204prolectedids
CITY OF C'UPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: $8,500
R*PERMITTYPE: Minor Building Permit PLAT CHECK TYPE: Re-roof
PRIMARY PENTAMATION
SFD or Du lex 7t>'f tL 1SFDWLR00F
USE: P I�1C�t3tl I, PERMIT TYPE:
WORK
SCOPE
FEE ID ROOF AREA
s,f.
1REROOFFRES 2,500
P?an
k f'r'om Naa t7Ch,ek
1 , h,
0"h"A%c'r Isis��-
�F �'Pit rxi:Irc�7> Ur`,Pt`Lr.'r Lfav
NOTE. These fees are based on the prefiWinairy in ormation mailable and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS LFee Resolution 09-051 Eff 74/10) FEE QTY/FEE MISC ITEMS
P/ol7
SzrppL PC Fct,
1'lionlr.i1lec/r_Llcc 1'Ic1=r CClrec:k.,
Permit Fee: $325.00
sllpp/. /isp Fc,v
/'hrtrrh./1Prc1r.-ZtE>c Perntil FCC,
C"onstruclion 1'cn
"Ic ousticol l:cricll VE'c':
Work Without Permit? 0 Yes 0 No 10.00
Plr.znrtr`ng, /"k,cs.
TI-o vel!)ouwne inaliorr
Strong;Motion Fee: IBSEISMICR 90.85 Select an Administrative Item
Bldg,Stds Commission Fee: 1BCBSC 51.00
SUBTOTALS: $316.85 $0.00 TOTAL FEE: $326.85
Revised: 9/14/2010
CITY OF �UPERTINO
PERMIT RECEIPT OPERATOR: patg
3 ITEMS OF 4 COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36913059 .00
DATE ISSUED. . . . . . . : 09/20/2010
RECEIPT #. . . . . . . . . BSC00011503
REFERENCE ID # 1OC90185
SITE ADDRESS . . . . . : 10_`)60 GLENVIEW AVE
SUBDIVISION . . . . . .
CITY CUI BERT INO
IMPACT AREA . . . . . .
OWNER LO:ZI NIELSON
ADDRESS . . . . . . . . . . : 10360 GLENVIEW AVE
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM TBD - O
FROOOFIING,BE INC DETERMINED LIC # 00096
CONTRACTOR . . . . . .
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC- --NEW-BAL-
----------
- --------- ----------
--------
---------- ------------- 1.00 0 .0
1BCBSC VALUATION 8, 500 . 00 1 .00 0. 00 0 .90 0 .00
1BSEISMICR VALUATION 8, 500. 00 0 .90
0 .00
00
1REROOFRES SQ FEET 25.00 325 . 00 0 .00 325 .00 ------0_
TOTAL PERMIT
326 .90 0 .00 326 . 90 0 .00
VOICE ID
DESCRIPTION VOICE ID -------DESCRIPTION
---------
- -----------
--------------------------- -
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS
605 FINAL REROOF
CITY OF
CITY OF C'UPERTINO
REF:OOF
CUPERTINO PERMIT APPLICATION
APN # Date:
Building Address:
/!LS-4,0 l e
Owner's Name: .4,o r Phone #:
HOA: Yes ❑ No es, provide letter from HOA
Contractor: Phone #: 1/08 s- q a`I O
ko® P k o o r
"i / r
Fax#:
Cupertino Business License #: Contractor License #:
�c$ 7568
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles .rte Asphalt Shingles
.01*� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings /' ❑ Provide I.C.C.E.S. Report#
,a- To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: 7'e e F F e-K(S4 it's S 6,a e Rob F
Inds +q `t � 4, 0S � Ir�Sfalt L( a � R. Cdw�P
C Vo
Residential Z - Commercial
Green Building: Please complete relevant portion of the Con.frmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions:
applicable, include in plan set & the sheet index.
Valuation: -185-,0
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 02/05/09