10070143 CITY OF CUPERTI v0 BUILDING PERMIT
BUILDING ADDRESS: 10205 VICKSBURG DR CONTRACTOR:KEN KHO PERMIT NO: 10070143
OWNER'S NAME: KEN KHO 10205 VICKSBURG DR DATE ISSUED:07/20/2010
NNER'S PHONE: 4083569299 CUPERTINO,CA 95014-3358 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
License Class Lic.# RE-ROOF REMOVE SHAKE AND SHEETING ROOF AND
30/36
Contractor Date LB FELT AND VENT 40YR LANDMARK CLASS A 25
1 hereby affirm that I am licensed under the provisions of Chapter 9. SQUARES
(commencing with Section 7000)of Division 3 of the Business&Professions
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:$7000
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:36907009.00 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 relatin; WITHIN 180 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 the
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.
RE-ROOFS:
Signature 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
inspection.
OWNER-BUILDER DECLARATION / L
Signature of Applicant: v Date:
I hereby affirm that I am exempt from the Contractor's License Law for one cf
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 compensatioi i,
will do the work,and the structure is not intended or offered for sale(Sec, 044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed con actors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(See.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. I 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 I 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 I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 5505,25533,and 25534.
Section 3700 of the Labor Code,for theerformance of the work for which this '' a
permit is issued. p Owner or authorized agent: ��/ f Date: ` /v /
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 mu:t 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 city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
virion the above mentioned property for inspection purposes.(We)agree to save
emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,sts,and expenses which may accrue against said City in consequence of the I 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. / 7(
Signature ! �v Date � J 6
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINC,CA 95014-3255
(408)777-3228- FAX(408)777-3333-buildino5cjoertino.o-c
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:
SITEADDRE�gS F ` ARK /G� � � BP#
OWIIERNAME OWNER ADDRESS
Ica-INC Lil 2
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledg-hent and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by h aving this permit issued in your name as the Owner-Builder. We
will not issue a buildirig permit until you have read, initialed your understanding of each provision, signed,and
returned this form to us at our official address indica-:ed. 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 reand initial each statement below to signify you understand or verify this information.)
ad
L
. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
r"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 liabl,:and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees whilo,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.
,k2. 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.
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3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
ect myself from potential financial risk by hiring E.licensed Contractor and having the permit filed in his or her
name instead of my own.
r; 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
—B. I 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
cnsidered an"employer"under state and federal law.
V6. 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 ✓vorkers' compensation disability insurance, and contribute to
unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject
Mento serious financial risk.
l[i 7. 1 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
li ensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
i performed under contract with a licensed general building Contractor.
understand as an Owner-Builder if I sell thy;property for which this permit is issued, I may be held liable for
any fin cial or personal injuries sustained by any:ubsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
(%4',nerBuilderFornt 2010.doc revised 04/14/10
�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 NAww.csib.ca.gov for more information about licensed
ontractors.
10. 1 am aware of and consent to an Owner-Build 3r building permit applied for in my name,and understand that
amt e party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financiall✓responsible for this proposed construction activity, I will abide
a applicable laws and requirements that govern Owner-Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions,'deletions, or changes to any of the
informa ion 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 licem,e,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 ire 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 b;e 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 constructior 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: LendE!r 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 accep ble to the cit i may be required to be presented when the permit is issued
to verify the property owner's signature
Property Owner's Signature: , 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 per,nit 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 E pply 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 pn?sented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwrrerBui.lderForm 2010.doc revised 04114/10
REROOF TEAR-OFF POLICY
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR,P.E., C.B.O., BU LDING OFFICIAL
CUPERTINO 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333- :uildinq(�i-)cupertino.org
PROJECT ADDRESS VI, 7APNd
OWNER NAME PHO JE iGt E-MAIL i
STREET ADDRESS CITY, ST NTE,ZIP FAX
CONTRACTOR NAME (9 LICENSE NUMBI R LICENSE TYPE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,ST.ATE,ZIP PHONE
I UNDERSTAND AND A JREE 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 and all dry-rotted wood shall be replaced prior to this
inspection. A building inspector will be availabl,- 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 inspe.-tion is required.
5. In-Progress roof inspection is required. Call fir 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 dow:i to the sheathing so a proper inspection can be
performed.
7. A final inspection and approval shall be obtainer from the building inspector when the re-roofing is
complete. To receive a final sign-off, the follow ng items will be verified:
a. Flat roofs shall have a minimum of 1/4"per f)ot of slope and must demonstrate there is no ponding.
b. Listings from approved testing agencies for ill pre-manufactured products used shall be available
on-site to review at the time of the inspectio i.
c. Proper spark arrestor installation.
8. NOTE: If you call for a tear-off or plywood nai ing inspection and the work is not complete, you will
be charged a re-inspection fee of$126.00. The r;-inspection fee shall be paid before another
inspection can be scheduled.
By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act
on the property owner's behalf.A understa nd a rec to comply with the re-roof policy stated Oove.
Signature of Applicant/Agent: Date:
ReroofPolicy_2010.doc revised 05/17/10
1
CITY OF CUPERTINO
FEE ESTIMATOR-- BUILDING DIVISION
UAPN:
DRESS: DATE: REVIEWED BY:
BP#: "VALUATION: 1$7,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY TOTAL APPLICATION
USE: SFD or Duplex ROOF AREA: 2,500 S f TYPE: 1R3SFDADD/REM
� a
OD
3 �
FEE ID
1 RERC OFFRES
NOTE: These ees are based on the relimina in ormation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-051 F_f: 7 I."09) FEE QTYIFEE MISC ITEMS
Permit Fee: $32'5.00
Work Without Permit? Q Yes No $0.00
{j
Strong Motion Fee: IBSEISMICR $0.70 0.0 hrs Standard Hourly Rate
131d�_, Stds Commission Fee: IBCBSC $11.00 $0.00
SUBTOTALS: $326.70 $0.00 TOTAL FEE: $326.70
Revised: 6/30/2010
CITY OF
CITY OF ("".'UPERTINO
REIZOOF
CUPERTINO PERMIT APPLICATION
APN#
Date-
Building Address:
Owner's Name: Phone #:
HOA: Yes
E] No �If es, provide letter from HOA �� � v� <17
Contractor: Phone #:
Fax#:
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
4"Wood 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 Mfgr. Installation Specs.,,
17
Job Description: '
P-4 ;\ �j
L CIcl-,r A
�J
• —lam - �s t \ t i V
Residential - Commercial S--
Green Building: Please complete relevant portion of the Corc§rmed Mth_Planning Dept. if
Green Building Checklist & attach it to the ap;:) ication or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 02/05/09
M.Indoor Air Quality and Finishes
1.Use Lo*No-V()C Unt 1 IAQ/Health pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0
3.Use Lowft VOC Adhesives 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 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y--yes 0
7.Seal all Expcisad PaWa6bm d or AAQF 4 IMI-lealth. pts y=yes 0
S.Use FSC Certified Materials for Interior Finish 4 Resource pts y--yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts yeses 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y--yes 0
' i 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y--yes 0
2.Use Rapidly Renewable Flooring Materials 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 IAOIHealth pts y--yes; 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts yeses 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y--yes 0
Total Points Available: 1401 130E---5-71
Total Points Project Received: 01 01 Q
w.
'54' �i
111 v �
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