07100077 CITY OF CLIPERTINO > : ` y�,�
BUILDINC DIY; PERIVIIT ���� ���� ����'� :'
;: > ..::.::..,..__ ,: ..:
PERMIT NO.
BUfI.D r�r,�qqn�ess�MPIRE AV MARTIN ��OSEPH L AND CELIA R 07100077 .
OWNER'S NAME: pERM]TLSSUEDATE
MARTIN J L A CELIA R 10159 ETIPIRE AVE 10/09/2007
NE: SANiTARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BU([.D(NG PERMITINFO
BLDG ELECT PLUMB MECH
� 0 � 0
i� p LICENSED CONTRACTOR'S DECLARATION
� V F I luicby affirm tha� I sm licenscd undcr provisions oCChapicr 9(commencine Job Description
: Z� with Scction 70(M)) of Division 3 of ihc Busincss and Profcssiont Caic, and my liccnse is TOUC H D� 1� 17 S Q C LA S S A
� a a in fuli focce and eCCect
j� Z Licensc Class Lic. # -
� F , � Datc Conuacwr
,� ARCHITECI'S DECLARATION
7 a a 1 undcruand my plans shall be uscd as public rccords
)aU
' m y Liccnsed Pn�fcssional
� y � OWNER-BUILDER DECLARA"[70N
� a� 1 hcrcby affirm �hat 1 am excmpt fram ttic Conuactofs Liccnsc Law Car ihc
` p o following rcuon. (Sccdon 7(131.5, Busincss and Profcssions Codc: Any city ar county
�,°, � which �cquires a permit to conswct, alur, improvc, dcmolish, or mpair any suuctucc
'? Z y prior ui i�s issuancc, also rcquires �hc applicant for such permit to filc a signcd stau�mcnt
- < �hat hc is liccnscd pursuant lo thc pmvisions of �hc Contrxtor's Liccnsc Law (Chaptcr 9 5 q. Ft. Floor Area Valuation
r t �(commcncing with Section 7000) of Division 3 0( thc Busincss and Profcssions Codc) or � 2 5 0 �
i�� that Vu is oxempt the�cfrom and the basis Cor tAe allcgcd exemption. Aay violadon of
Section 7031.3 by arty applicant Cor a peimit subjecu ihe applicant to a civil penalty of Number Oeeupaney Type
not more than fivc hundred dollars (5500� 3 2 6 2 4 0 3 ���
❑ I, as owncr o[ [he property, or my employces with wages u �heir solc rnmpensation,
will do the xro:ic, snd the suucture is not intended or offered forsale (Sec.7044, Business Re uired Ins eCtI0I1S
and Professions Cade: The Conleacmr's l.icense Law does not appty m an owner of Q p
propeny who builds or improves thercon, and wha daes such work himselCor tAmugh his
own employccs, providcd that such improvemenLC are noe intended ar a(Cered for sala If.
however, the building or improvement is sold within one year ot completion, ihe owner-
builder will have the burden ot pmving that he did noi huild or improvc for purpase of
sale.).
I, az owner of the property, am exclusively conuacting wiW licensed rnnuxtnrs to
nstruct the projea (Sec. 7044. Business and Pro[essians CodeJ The Cootraccor's Li-
c w docs not apply lo an ownu of property who builds ar improves Ihe�eon, and .
who vacu [or such p' with a conuactor(s) lianted pursuant to �he Convurors
L' Law.
❑ exempt un . B�c P C for this reason
O o
WORKIIt COM A DECLARA170N " � .
I herc affirm under penalty of perjury one o[ the folbwing declacations:
�] t h:.�e and will maintain a Ceni6catc ot Cansent to sel(-inswe for Workcrs Compen-
sation, as provided for by Secrion 3700 of the Labor Code, for tAe performancc of the
work for which Wis permit is issued.
❑ I have and will maintain Workefs Compensation (nsuronce, az rcquircd by Scction
3700 of the Labor Codc, Cor �he performancc of the work for which this permit is issued. �
My Workers Compensatian Insurance carricr and Poliry numbcr uc:
Cartier. Polity No.:
CERTIFlCATE OF EXEMP'fION FROM WORKERS'
COMPENSATION INSURANCE �
(ihis section necd noc bc canplctcd if the pertnit is for ane hundred doRars (S 100)
nr Icss.) •
I cenify that' thc performancc ork for which �his pertnit is issce4 1 shall nac
amploy any n in any manncr bccomc subjcct to U�e Workcrs' nsation
Laws of Ca mia D
Applicam
NOTIC A A. I. aftcr makmg �his ' tcate of cmpGon, you shauld
bccom s jcc[ ro �hc rkcr's Compcnsation provisions of ihc Lahor Codc, you must
� O fortt�w omply wiih such provisians or this permit shall bc dccmcd revokcd.
� ""' CONS7RUCfION LENDING AGENCY
(—�i ►�-� [ hemhy aClirm Uiat there is a consuuction Icnding agency Cor the perCortnance uf
R; � ihc work for which �his permi� is issued (Scc. 3097, Civ. CJ �
a Q Lendcr's Namc •
a z L.ender's Address
(� � I certify Uia� 1 havc rcad ihis applicuion and siatc �hat Urc ahave informauon is
w � - ' cortcct. I agree to comply with all city and county arcfinances and s�ate laws celating w
rJ U building conswction, and hneby authoriie representatives of �his city to enter uFmn the �
� W above-mcnuoned property (or inspecuon purposes.
(Wc) agrce �o save, indcmni(y and kecp harmless the City o( Cupertino against
� r, liabiliuu, judgmcn�s, costs and which may in any way acrnc against said City
(,) z in con uencc of thc granting C u permit.
►'� APP AN'1' UNDERSTAN ND LL L WITH AL INT Issued by: Date �� �(�?
SOU E REGULATIO �
Re-roofs ` ��
gn ure Appli dContractor Duc
HAZARDOUS MATERIALS DISCLOSURE Type of Ro �f
Will Uu a licant or futwc building occupant s�ore or handk ha•rardous matcrial
az deGncd by 1he Cupertino Municipal Cadc, Chaplcr 9.12, and the Health and SaCcty
c«� Section 25532(a)? All roofs sl►all be inspected prior to any roofing material being installed.
❑ Ycs No
Will thc applicant or Cutu building occupant use equipmcnt or dcvioes which If a roo is installed witho rst obtaining an inspection, I agree move -
cmii harardous air contaminants az dcfncd hy �he Bay Area Air Quali�y Managcmcnt all ne ma :erials for in ec!'on.
a$u�c�? y�
❑Ycs f�Wu ~
IhavcrcaJ�heha�ard �\ rialsrcyuircmentsundcrChaptcr6.95afthcGli(or r
nia calth & SafcryCodc, Scc 75505.25533 and 25534. f undc d �hatiCNc 6uilding
d not currcn�ly havc a tc 4�� nsibiliry y occupam af Wc
m rcmcnawhichm t i (aCcnif arae��r. S�gn ture eEA licant Date
ncrorauthori dagcni D„� All roof coverings to be Class "B�� or better
��/ � � v `
CITY OF C;UPERTINO
n.�
RE��O{�F
CUPE�TINO PERMIT APPLICATION FORM
APN #��� `P � C/,��. V U Date�a a 0�
7
Building dcj�'e�s�� � p� ' � �( I � �
�/ l lT
O ner's N^ e• � !+ � � � ! ! � Ph � d� p� �J �" / �' V �
d�
Contractor: � /� License #:
(
Contact: ��� Cupertino Business License #:
Type of R�of Covering:
Ea�isting: Pro osed:
� Built-Up Roof � Built-Up roof
❑ Asphalt Shingles d Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report #
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With Cu��ertino's Tear Off Policy:
Job Description: � j � �- G
� !� � ��� ��r, < l ��s �4
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plaruiing D�t. if
there are any restrictions: LJ
Cost of Project: Type of Construr,tion: Occupanc grou .
�. � �-� � . <<= ��
Qri. �f
Applicable Fee ID Fee Description Fee Group
BPERMFEE 31dg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
- Community Development Department
' - Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
Fax: (408) 777-3333
Building I)epartment
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance, you must agre�� to comply with 1997 UBC Standards
and manufacturers specifications on re-:�oofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the bui _ding inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
� 2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
- --
5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new matf �rial down to the sheathing,
so a proper City inspection can be perfc rmed.
7. NOTE: If you call for a plywood nail ir.spection and the job is not ready,
you will be charged a re-inspection fee ��f $176.18. The re-inspection fee must
be�aid before another inspection can be scheduled.
IMPORTANT
1. Flat roofs must have a minimum of 1 /4 " per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
' me: a J � P I l h . / ' � �7` � ���
Home�wner s N�
�
Job Site Address: U � � / � � I � / � /-� � �'-"
Roofing Company N me: _ C �/ �
7 / �
A licant's Signa . . ate: � ��
PP — t�` - �
Greg Casteel
Building Official
Revised 11/2/04
CITY OF ��UPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ......... 326Z4035.00
DATE ISSUED.......: 10/09/2007
RECEIPT #.........: BS000002944
REFERENCE ID # ...: 07100077
SITE ADDRESS .....: 10159 EMPIRE AV
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OVJNER ............: MARTIN JOSEPH L AND CELIA R
ADDRESS ..........: 10159 EMPIRE AVE
CITY/STATE/ZIP ...: CUFERTINO CA, 95014-1204
RECEIVED FROM ....: JOSEPH L MARTIN
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: MARTIN JOSEPH L AND CELIA R
ADDRESS ..........: 10159 EMPIRE AVE
CITY/STATE/ZIP ...: CUFERTINO CA, 95014-1204
TELEPHONE .........
FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -
BPERMFEE VALUATION 2,500.00 83.16 0.00 83.16 0.00
BSEISMICRE VALUATION 2,500.00 0.50 0.00 0.50 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 83.66 0.00 83.66 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 83.66 #6811
TOTAL RECEIPT : 83".66
OWNER-BUILDF R VERIFICATION
1. (Check one) I or my immediate family Iparent,.spo�se or child) will perform:
p,. � All the work authorized by this permit
B. _ A portron of the work
C, _ None of the work
If B or C is checked, c��mplete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A, _ All of the work
B, _ A portion of the wcrk (complete section below)
Contractor Address/City Phone # State License # Type of work to
be erformed
3. I will utilize unlicensed person(s) �ther than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' coxr.pensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
...........................................................................................................................
I declare under penalty of p jury th e at ove is true and correct. I have read and understand the
Owner-Builder Informatio (reverse s e). �
. � ,- � v � 7
Property Owner's Signa Date:
��;Yj/� � � .
Job Address: Permit #
Any chang.es to the information provided on this form shall be submitted to the City of Cupertino Build
De.partment.
Community Development
� �= 10300 Torre Avenue
; �.
,�'� ` ; �;• . Cuperkino CA 95014
Telephone (408) 777-3228
C1TY OF Fax (408) 777-3333
''UPERTINO
Buildi:n De artment
JOB ADDRESS: �, PERMIT #
�, • � ��j � f�� r..c� ;�.—1,' �% OC�c:� `?�
OWNER'S NAME: ; �'Sf't�`! _ "L�c�.�� ►�> PHONE # a� " � �
GENERAL CONTRACTOR: • FAX #
--' ���,= a �
I am not using any subcontractor : '
Si�;nature Date
Please check a licable subcon ctors and com �lete the followin information
SUBCONTRACTOR BUSIriESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
IIectrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heatin.g
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
�� Tile �
l .� _,�' ,,� �: ` "�' �� C' 7
; �%� � � -_� � �
/ Owner/ ate
�-" , . __
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