10070002 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7463 TIPTOE LN CONTRACTOR:- 1 D PERMIT NO: 10070002
OWNER'S NAME: JOHN SHELCHUK (k—) 2. .
e t' 4C Ck V\I ek .,(_- 1-E DATE ISSUED:07/01/2010
4ER'S PHONE: 4153785989 l._%`` I PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB
f.,-nseClass Lic.# .x'2-116 MECH f— RESIDENTIAL COMMERCIAL
Contracto 4 abs Date-?— �" � V
JOB DESCRIPTION:TEAR-OFF OLD SHAKES INSTALL GLASS CAP CLASS A
I hereby ►rm that I am licensed under the provisions of Chapter 9
SHEET INSTALL FIRE TREATED HEAVY SHAKES CLASS A
(commencing with Section 7000)of Division 3 of the Business&Professions ASSEMBLY 33SQ
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:$23000
permit is issued.
APPLICANT CERTIFICATION APN Number:35928005.00 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. dditionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point s r regulations per the Cupertino Municipal Code,Section
9.18.
` Issued by. Date:
Signature ��--- Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
therebyaffirm 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: Date:
Business&Professions Code)
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
1 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&
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 de,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 or t ized agent:
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 her y 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 hich 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
mify 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
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
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR-- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: L�?Q(�U'� VALUATION: $0
-PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY TOTAL APPLICATION
USE: SFD or Duplex ROOF AREA: 3,300 S.f. TYPE:
as
cc
3 �
FEE ID
1REROOFFRES
NOTE: Thesefees are based on the preliminayy in ormation«vailable and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (1'ee Resolution 09-051 r'ff.' 7//:7091 FEF QTY/FEE MISC ITEMS
P, F",
Permit Fee: $420.00
1_
Work Without Permit? Q Yes No $0.00
Strom Motion Fee: $i).00 Select an Administrative Item
Bldg Stds Commission Fee: $).00
SUBTOTALS: $42!1).001 $0.00 TOTAL FEE: F $429.00
Revised: 5/27/2010
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot :
APN 35528005. 00
DATE ISSUED. . . . . . . : 07/01/2010
RECEIPT #. . . . . . . . . BSC00010748
REFERENCE ID # . . . : 1OC70002
SITE ADDRESS 74E3 TIPTOE LN
SUBDIVISION
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOHN SHELCHUK
ADDRESS 7463 TIPTOE LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM WERGELAND ROOFING C
CONTRACTOR TBI) - TO BE DETERMINED LIC # 00096
COMPANY TBI) - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- - --------- ----
1BCBSC VALUATION 23, 000 . 00 1 .00 0 . 00 1 . 00 0 . 00
1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
1REROOFRES SQ FEET 33 . 00 429 . 00 0 .00 429. 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 544 . 00 0 . 00 544 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -------------------
CHECK 544 .00 #5911
---------------
TOTAL RECEIPT 544 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
REROOF TEAR-OFF POLICY
COMMUNITY DEVELOPMENT DEPAR rMENT•BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O.,BUI-DING OFFICIAL
10300 TORRE AVENUE•CUPERTINO CA 95014-3255
CUPERTINO
(408)777-3228•FAX(408)777-3333•.)uilding(okupertino.org
PROJECT ADDRESS JJ &3, ,I%T L�►+•�£ APN#
OWNER NAME PHOIJE E-MAIL
STREET ADDRESS / CITY, ST\TE,ZIP FAX
CONTRACTOIn�N to a �D n _ _� O LICE;SE 2I`i`I LICE-SE TYPE BUS.LIC#
VJ
COMPANY NAM •C� `7E-�iIL1=OvAA`V' &f-L rO 4VL•� �►X
STREE�^ADDRESS� V � O NE
�� CITY ST,. ZIP `a` P4arz—4/
L- I UNDERSTAND AND A3REE TO THE FOLLOWING:
1. The re-roof project shall comply with all applica)le provisions of the 2007 California Building Code.
2. You must schedule all needed inspections a minimum of one day before the requested inspection date.
Please schedule inspections online or call (408)777-3228 between 7:30-3:30 (Mon-Fri).
3. Tear-off roof inspection is required. Please call for tear-off inspection after the roof is torn off and all
the nails/fasteners have been removed. Any aid all dry-rotted wood shall be replaced prior to this
inspection. A building inspector will be available within one hour.
There are special hours for this service: 7:30 - 10:30am and 1:00—3:30pm (Mon—Thurs);
7:30 - 10:30am and 1:00—2:30pm (Friday).
4. If plywood is installed, a plywood nailing inspection is required.
5. In-Progress roof inspection is required. Call for an in-progress roof inspection to verify building is
weather tight after installation of approximately 25% of the roofing material.
6. New roof coverings shall not be applied without first obtaining all inspections 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.
7. A final inspection and approval shall be obtained from the building inspector when the re-roofing is
complete. To receive a final sign-off, the follo A ing items will be verified:
a. Flat roofs shall have a minimum of 1/4"per loot of slope and must 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 inspectic n.
c. Proper spark arrestor installation.
8. NOTE: If you call for a tear-off or plywood na ling inspection and the work is not complete, you will
be charged a re-inspection fee of$126.00. The :-e-inspection fee shall be paid before another
inspection can be scheduled.
By my signing below, I certify ch f the following it,true: I am the property owner or authorized agent to act
on the property owner's beha . I u derstand and agre,- to comply with the re-roof policy stated above.
Signature of Applicant/Agent: Date:
ReroofPolicy_2010.doc revised 05/17/10
ITY OF ( G
CITY OF C.UPERTINO
La RE ORF
CUPERTINO PERMIT APPLICATION
APN# Dat i
Building Address:
b 3 P To
Owner's Name: Se t► s )r% a i_c Lv Ic Phone #:
%-I 1r-3-> % - S
HOA: Yes ❑ No ❑ If Yes, provide letter from HOA
W�24A Phone#: 41-6-441-6-4Contractor: 1q- Cl `� `�
Rv�r(s 4`(070
Z Z 3 1r%iv-�.or�. pt.�l?... Ar-` G,*(04Is Fax#:
Cupertino Business License #: Contractor License #:
6 �'2�1f6 c--3
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
a,- Vood Shakes q.-Wood Shakes S
❑ 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 Description:,�.ep %.- Of-f- v'-D 1 ��
(I P C. l IsS A s NA t
s
Residential 0-` 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, include in plan set & the sheet inc.ex.
Valuation: K..
2
I Have Rea , erstand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 02/05/09