07100164 CIT�' OF CUPERTINO '
BUILDING DIVISION �ERMIT
C()��'�tE?�G�C1� IN�t�R�:�TION: ;
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BUILDING ADDRESS: PERMIT NO.
1 �37Fi� MFRRT'�"�' �� � P R
NER'S NAME:
S CONTROL NO.
PHONE.
BUILDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH
C� � 0 �
> o LICENSED CON'fEtACTOR'S DECLARATION JOU DeSCilPt10❑
��.�"7 [ hercby aflirm lhat 1 am liccnscd ualcr provisions of Chaptcr 9(commcncing
:� with Scction 7000) of Division 3 of ihc Busincss and Protcssions Codc, and my liccnsc is
� y in full forec and cCfecL TEAR OF F WOOD SHAKES � F I LL SHEETING AS NEEDED �/� O
3 ? Licensc Clus t-�• �
p Da�c Co�tracwr LBS FELT� INSTL 28 SQ METAL TILE
: � ARCHITECI'S DECLARATION
"� I undcrstanJ my plans shall fic uscd as public rccords
ia
U
� Liccnscd Pro(cssional
� a OWNER-BUILDER DECLARAT(ON
� .�
1 hcrcby aCfirm tha� 1 am cxcmpt from thc Contractor's Liccnsc Law for thc
j o following rcuon. (Scction 7031.5, Business and Profcssions Codc: Any ciry or county
; Pi which rcquims a permit to conswc4 alicr, impmve, dcmnlish, or �cpair any structurc
;� prior io i�s issuancc, also �cquires ihc applicant tor such permit io filc a signcd sutcment jq Ft. FIOOi AieS Valuati on
�< � h a � h c i s l i c c n s c d p u rs u a n� l o thc provisions of U�c Con�ractor's Liccnsc Law (Chapicr 9
-$ (commcncing wi�h Scction 7000) of Division 3 a( �hc Busincss and Profcssions Codc) or
C.-. Ihat he is exempt thecefrom and the basis for �e alicgcd exemption. Any violauon of
Section 7031.5 by arry applicant for a pem+it subjects �he applicant to a civil penalty o( APN NlliClber eeupaney Type
not more �han five hundred dollars (5500).
❑ I, as owner o[ ttie property, a my employcrs with wagu u �hcSr solc compensation, 316 3 5 011 . 0 0
will do the worlc, and the stcuclure is notintended or offered for sale (Sec. 7044. Businus Required Inspections
and Pro(essions Code: The Conuactor's License Law dacs not apply to an owner of
property who builds or improvcs �hercon, and who does such work himself or through his
own employces, providcd tha� such improvemenLS are not intended or otfereA for sale. IC,
however, �he building or improvement is sold within one year o[ completion, Ihe owncr-
builder will have �he burden ot proving �Aat he did not build or improve Cor purposc of
sate.).
❑ I, as awner of the property, am ezclusively convacting wilh licensed rnntractors to
wnstruct the project (Sec. 7044. Business and ProCessions Code:) The Contnctnr's Li-
ccnse Law does not apply �o an ownu o( property who builds or impraves ihe�eon, and .
who conuacts for such pmjeac with a conuactor(s) licensed pursuant to the Convactor's
Litense Law.
� I nm ezempt unda Sec , B& P C for ihis rcuon
aer Date
WORKFR'S COMPENSA'i70N DECLARATION
I dercby affimi under penalty ot pery'ury one of �he following declarations:
❑ i hsve and will maintain a Ceni6cate of Consent to self-insure for Workcr's Compen-
sation, u provided for by Section 3700 of the Iabor Code, for the performance of �c
work for whicd this permit is issued.
havc and will maintain Worker's Compensation Insurana, as icquircd by Scction .
3700 oC the Labor Cade. Cw the pedormanee o[ the worlc for which �his permit is issued.
My Worker's Compensation Insurana cartier and Polity numbcr arc:
Cartier: �S'�4`�-R� �NN� Policy No.:
1 lrr9 i: v
CERTIFICATE OF EXEMP'I70N FROM WORKERS'
COMPENSATION INSURANCfi
(IT�is section nud not bc comple�cd if the permit is for onc hundred dollazs (S 100)
or Icss.)
I cenify ihxi in thc performa�c of thc work fw which �his permit is issucd, I shall not
employ any person in any manncr so as w becomc subjcct �o ihe Workcrs' Compensation
Laws of Cali(omiz Dalc
Applicant
NOTICE TO APPLICAM: If, aftcr making this CcrtiGcatc of Excmption, you should
bccome subjcct to lhe Workcr's Compcnsation provisions of �he l.abor Cndc, you muu
� O foMwiih comply with such provisions or this permit shall bc dccmcd rcvokcd.
� ""' CONSTRUCTION LENDING AGENCY
�� 1 hcrchy at1'irtn ihat there is a consuvctinn Iending agcncy Ibr thc perfortnana of
;� � work for which Ihis permit is issucd (Scc. 3097. Civ. C.) .
1 Q Lendcr's Namc
� z Lcnder's Address
1
) � ! certify Iha� 1 havc rcad this application and state ihaz thc abovc infocmaliun is
►-� cortca I agece io comply wi�h all city and county oniinances and suk laws rclating io
j U building consuuction, and hcreby aWhori�e represcnutivcs of Uiis city to cntcr u�n thc
� W abovc-mcnuoncd properry for inspccuon pur�wses
� a (Wc) agrce �o save, indcmnify and keep harmless ihe City of Cupertino against
�� liabititiu, judgmen�s, costs and expenses which may in any way accrue against said City
) z in consequencc oC the granung oC this permit. Date
�"� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOU REGUL NS.
�' �3""� Re-roofs
S' natu �;�uco� �� D e 1 c Type of R oof
HAZARDOUS LSDISCLOSURE
w11 Ihe applicant or futurc buil cupant storc or handlc harardous matcrial
^� dcfincd by the Cupenino Municipa! Codc. Chaptcr 9.t2, and chc Hcal�h and Safety
Ic. Scction 25532(a)? � All roofs shall be inspected prior to any roofing material being installed.
❑ y� iA ""
Will thc applicant or luturc building occupant usc cyuipmcnt or dcvices which
If a roof i� installed without first obtaining an inspection, I agree to remove
cmit harardous air contaminants as dcfincd hy the Bay Arca Air Quality Managcment all new n aterials for inspection.
District? �
❑ vcs a`f�
I havc rcad the ha�ardous ma�crials requircmcn�s undcr Chap�cr6.95 0( ihc CaliCoo- /�
nia Hcal�h & Safcry Codc. Sections 25505, 25533 anJ 25534.1 unckrstand �hat iC ihc building �U�� J/�4 �
docs no� curtently havc a tenan4 �at it is responsiAiliry w �rotify ihc occupant nf thc
rcyu' mcnts w' h must be met prior tss � or a c��;r�a� or o����ry. '"nature �p � ant Date
��� All roof coverings to be Class "B or better
Owncr r authori d agcnt Datc
f��l l ��l ��
CITY OF ��UPERTINO
:�' RE [20aF
CUP��T1N0 PERMIT APPI.ICATION FORM
APN # Date:
�� � U� . OC.'� U"
Building Address:
� �i 7G 3 /''fP<�, ff �✓�.
Owner's Name: Phone #:
� � n. .SAMw r' �l D j� � T 3� (, S'ti �
Contractor: License #:
�,r�c'i.� ��iN s,��,f G ��i 7 z�
Contact: Cupertino Business License #
�i c �AE / L r � �
Type of F;oof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
D Asphalt Shingles ❑ Asphalt Shingles
`� W ood Shakes ❑ W ood Shakes
�O Wood Shingles ❑ Wood Shingles
❑ Other (Specify) � Other (Specify) /'�'��7�1 7�'�<
Nutnber of existing coverings ❑ Provide I.C.B.O. Report # s"(a2 (i
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With CL pertino's Tear Off Policy:
Job Description:
•� ��1 .�ef ,/(t��e��� Ne��l� 'S�v /Ss ��' �.�. �( 2�'�r���a� �j.�
Residential � Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D�t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
/ t iJ
Qty. if
Applicable Fee ID Fee Description Fee Group
� BPERIVIFEE Bldg Permit Fees BIJILDING
BENERGY Energy BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BLTILDING
Community Development Department
� � � Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
Fax: (408) 777-3333
Building l�epartment
Subject: Re-roofing policy for the C�ity of Cupertino
1. Prior to permit issuance, you must agrE e to comply with 1997 UBC Standards
and manufacturers specifications on re��roofing.
2. New roof coverings shall not be applie�i without first obtaining all inspection
and written approval from the buildin�; inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to an3� roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off apprc�val.
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 i irst obtaining an inspection,
will require the removal of all new mai erial down to the sheathing,
so a proper City inspection can be perf��rmed.
7. NOTE: If you call for a plywood nail i:zspection and the job is not ready,
you will be charged a re-inspection fee of $176.18. The re-inspection fee must
be paid 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 abovf� stated policy on re-roofing.
Homeowner's Name: v/lJiw SA''
r
Job Site Address: /�l7G 3/�Prri'f! Cv �-
Roofing Company Name: Li/�vs�P�M ���'�`� s�. s�*S
Applicant's Signature: Date: �v' Z3 ''�
Greg Casteel
Building Official
Revis��d 11/2/04
y . Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
Fax: (408) 777-3333
Building lDepartment
REROOF TEA.R OFF POLICY
1. You must schedule an inspecti�n for the tear off the da,y before
you wish the inspection to be rnade. The procedure is to call the
Building Division (408) 777-32'_8 be�cveen the hours of 7:30 a.m. and
3:30 p.m. to request a next-day inspection.
2. When the roof is torn off, the nails have been removed or driven in,
and all of the dry-rotted w.00d has been replaced, you must call the
City Building Division. An inspector will be there within one hour.
There are special hours for this service: from 7:30 a.m. to 10:30 a.m.
and 1:OOp.m. to 3:30 p.m., Mor�.day through Thursday and from
7:30 a.m. to 10:30 a.m. and 1:00 p.m. to 2:30 p.m. on Friday. (Note:
Building inspectors are. on lunc�h break from 11:30 a.m. to 12:30 p.m.
and will not be called during tliat time. City Hall is closed between
12:00 and 1:00 p.m. daily.)
3. If you call for a tear-off inspec and the job is not ready, you will
be charged a re-inspection fee c�f $176.18. The re-inspection fee must
be paid before another inspec tion can be scheduled.
Greg Casteel
Building Official
Revise<i 8/13/04
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI'� RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blc: Lot:
APN ......... 31�35011.00
DATE ISSUED.......: 10/23/20�7
RECEIPT #.........: BS)00003057
REFERENCE ID # ...: 07100164
SITE ADDRESS .....: 19763 MERRITT DR
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OVJNER . . . . . . . . . . . . . VI PIN SAMAR
ADDRESS ..........: 19763 MERRITT DR
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2406
RECEIVED FROM ....: MI�HAEL D LUNNEBORG
CONTRACTOR .......: MI�HAEL LUNNEBORG LIC # 25896
COMPANY ..........: MI�HAEL LUNNEBORG ROOFING
ADDRESS ..........: 1328 WHITE OAKS RD
CITY/STATE/ZIP ...: CAKPBELL, CA 95008
TELEPHONE ........: (831)278
FEE ID UNIT QUANTITY ?�MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 15,750.00 234.36 0.00 234.36 0.00
BSEISMICRE VALUATION 15,750 1.60 0.00 1.60 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 235.96 0.00 235.96 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 235.96 VISA
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TOTAL RECEIPT : 235.96