07110140 CL'TY OF CUPERTINO
BUILWNG DIVISIO;� , PERMIT ���R�������������
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PERMIT NO.
eui��►�c�c�E�LM CT TBD - T� BE DETERMINED 0 711014 0 ,
PQtM1T LS6UE DATE
VER'S NAME:
BIATO JACOB � 11/26/20
SAMTARY NO. CONTROL NO.
PHONE:
BUILDING PERMii' INFO
ARCHITECC/ENGINEER: BLDG ELECT PLUMB MECH
� 0 � �
q p a LICENSED CON7RACTOR'S DECLARATION JOb DCSCT1pL10I1
V I hcreby a([icm that I am licensed undcr pmvisions of Chapicr 9(commencing
� wiih Sccrion 701x)) oroivision 3 of thc Busincss and Protcssions Code. and my liccnsc is T/ � S HA KE , I N S TAL L P LYWOOD , I N S T L L # 3 0 F E LT AN A
�= y in full focce and ef f '�' ''
��z ��co�acc�au -3� �ic•� `� 31 3 1 z LIFE TIME SHINGLE S # 2 1 C L A S S A� N E L S O N R O O F I N G PD
: �. o�e��• �'eK'' � " �� , ''` r `' 1 �' B S L 112 6 2 0 0 7 3 9 3 6 0
� ARCHITECI'S DECLARATION
� 1 undctsund my plans sAall bc used u public rccords
cc
�yU
4 p y Liccnud Pcufcssianal
y � OWNER-BUILDER DECI.ARATION
q I hercby affirm that 1 am excmpi Crom U�c CoNnctor's Licensc Law for thc
i p O following �casoa (SccGon 7031.5, Busincss and Rofecsions Cafc: Any city or county
y^ Pi which mquims a permit to consvuc� altcr. improve. demolish. ar �cpair any swcw�c
prior to i�s issuancc, alsu rcquires �hc applicant (or such permit to file a signcd sta�emcnt Ft Floor Area Valuation
� Z �� �� licenscd pucwani to �hc provisions a[ thc Conuactar's Liccnsc Law (Chap�cr 9 S9� $ 8 5 0 0
Y F$ (com mc n c i n g w i i h S e c t i on 7000) of Division 3 of Ihc Busincss und Profcssiona Code) or
y�... thai he is exempt thaefrom and the 6ssis for the sllcged exempdon. My violauon of
Section 7031.3 by a�ry applicant for a pem�it subjecu ihe applicam w a civil penairy of 3 6 2 01011 .A9� Number Occupaney Type
not mo+e � han f ive hun drc d d o l l a r s ( 5 5 0 0)•
❑ I. u owner o[ tl�e property. or my emptoyees with wages u thc'v sok compensation,
will do �he wodc. and the strucwrc is not intended or offeted for saie (Sec. 7044 Busi�rss Required Inspeetions
md Rofessiona Code: The Conuacar's Lianse Law docs nat apply to an owne� of
property who 6uilds or improves �hucun, and who does such work 6imself or �Mougd his
own employea, pmvided that such improvemenls ue not inanded or ollered Cor sale. If,
however, the building or impmvement ia soid within one year o[ compledon, ihe owner-
builder will have the burdui of proving IAa� he did not build or impcovc for purpose of
ulc.).
0 I. u owner of the property. am exclwively conuacting wi�h tianaed conuactors w
constrvct �he projea (Sec. 7044. Business and Pro[usions Cade:) The Contncmr's Li-
cense I�w does nol apply to an owner of property wha builds or improves thneon. �nd ,
who convacu for such pmjects with a convutor(s) ticensed pursusnt to �he Contractofs
License Law.
r'1 1 am exempi under Sec. , H& P C for this rcason
ner Date
WORKER'S COMPENSATION DECLARATION
I I hetcby affirm under penalty o[ petjury one of the following declaradons:
❑ I hsve and will mainuin a Cenif cate of Conaent lo ulf-insure (or Workcrs Compen-
ation, u providcd for by Section 3700 of Ihe Labor Code. for the performancc of �he
ork for which Ihis pertnie is issued.
❑ I havc and will maintain Worker's Compensation Insunnce, u required by Section .
3700 of ihc Labor Codc. Cor thc pedormance of Ihe work for which �his pe�mit is issued.
My Workers Compenaatiaa Insurancc cartier aed Poliry number ue:
Cartiu; �r�l� �(J�/�Y7 Polity No.ilL( 7d 5-�
CERI'IFICA7'E OF EXEMPfION FROM WORKERS' ,
COMPENSATION INSURANC6
(fhis section necd not bc complctcd i[ the pecmit is far anc hundred dollars (S 100)
or less.)
I cenify that in t6c performance of ihc work Iw which �his rermil is issue4 ( shal� eut
employ any person in any manner w as w bccome wbject to the Worlccn' Compensation
Laws of Califomia. Datc
ApPlicant ,
NOTICE 7'O APPLICAM: If, allcr making �his CcniCcatc of Excmption, you shoulJ
baome subjcct to �hc Workcr'a Compensation p�ovisions of ihe Lat+or Codc, you muu
� O foMwitd comply wi�h such provisions or tRis permil shall 6e dccmed mrokcd.
z '"' CONS7'RUCf10N LENDING AGENCY
(- ►�-� 1 M.�eby �rm �hat U�cro is a consuuctinn Icnding agcncy for thc perfortnar�cc u! .
a. ihc work for which this pemiit is issued (Scc. 3097, Civ. CJ ,
LL� Q Lendcrs N�mc
a z L,cnde�s Addness
(� � I certi[y �hat I have rcad Utis application and su�c iAa� thc above infamauun is
w � cortcc�. ! asree w comply wi�h all city and counry onlinances and suk laws rcladng w
0 U building consuvction, and he�eby authoria �cpresentadvcs of Ihis city w cnter upon Ihc
� W ahove-mcntioned property tor inspenion purpaus
a (Wc) agree to save, indcmnify and kecp harmless the Ciry o[ Cupertino against
� y liabilitiu, judgmcnu, cos�s and expenscs which may in any way acccuc against aeid City
V z in consequence oC the granting ot �his permiG Date �. '�, ��7
� APPLICANf UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by :
SOURCE G �S. /
/. ��- //' ZG--� 7 Re-roof: /'��
Signu ofApplicanUConuactor �°� T of Roof
HAZARDOUS MA7'ERIALS DISCLOSURE YP
wll the applicant or futwc building occupant storc or handlc ha•raMous matcrisl
dcfincd by the Cupertina Municipal Codc. Chap�cr 9.12, and the Hcal�h and SaCcty
:�. Section 25532(a)? � All roof : shall be inspected prior to any roofing material being installed.
D Y� �
If a roof is installed without first obtaining an inspection, I agree to remove
Will U�c appiicant or futurc building accupant usc cquipmcnt or cicvices which
cmit harardous air conisminan�t u fincd by the Bay Arca Air Qusliry Mamgcmem all new naterials for inspection.
�:.�;���
❑ Y« �o �
1 havc rcad the ha�udous maicrials rcquiremcnts undcr Chaptcr 6.95 of thc Califor- / /
nia Hcaltlf & SafctyCode. Scctiau 25505.25533 and 25534.1 undcrs�v�d ihu if Uu 6uiiding � l� —�!� d�
does not curtcn0y ha a tcnan4 ihat it is my responsibili�y to noufy thc occupant of tAe
rcquirc �s ni m� x�� �a� ���� ora c�„�r,�� ora���r. Signatut e of Applicant Date
�� �` G � All roof coverings to be Class "B" or better
Ow r 3uthari�.cd agcnt Datc '
. � � CITY OF CUPERTINO
R�,ROOF
CUPEi�TINO PERMIT ��PPLICATION
, Q
APN # � �/� !� ) l �, Date:
/ �.�
Building Address:
� � � � Z .�-Z.r� c i �-� � �'�r� Tix�ty C' �1 - � �� � 4
Owner's Name: Phone #:
j? i,�C'� ��4 � �' /� C�G�'�''� � Z�� _ C l � S��
Contractor: Phone #: t��� �' ) 2 Z S- 3 Z� �
�c,�E2 S'oX %� O c'� r"�� �l l, . /
Fax #: l��'�� 7� S 3 Z 2`�.
Cupertino Business License #: Contractor License #:
C-_�� �3`'�37Z.
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles m�Asphalt Shingles
� Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings ❑ Pro�ide I.C.B.O. Report #
0 To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: �� s ���� ; � ti 5� �� �� �-? L y C c%�C' /) , f F c� S �� � av � ;,�1 �_ L
� Z � -�
1 � � � ��-2 �- �> i-/� ,�I C � �� � . /e� � � t/ �i�ll c � C � C /i S S �l
Residential �� Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning D�t. if
there are any restrictions: L�
Valuation: �
���'�,• c'v
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
S� ure
- � Community Development Department
' Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
Fax: (408) 777-3333
Building :Department
Subject: Re-roofing policy for the ��ity of Cupertino
1. Prior to permit issuance, you must agr �e to comply with 1997 UBC Standards
and manufacturers specifications on rE-roofing.
2. New roof coverings shall not be appliE d without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the bi�ilding 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 Cih�, the following steps are
required:
1) Pre-inspection and/ or tear off appi oval. �
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywood nai� inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new mz terial down to the sheathing,
so a proper City inspection can be per �ormed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fe�� of $176.18. The re-inspection fee must
be �aid before another inspection ca�i 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 or. the job site at the time on inspection.
I understand and will comply with the abo� e stated policy on re-roofing.
Homeowner's Name: /��i� G' �� � �' ��
,
Job Site Address: l�i S 2 :� Z i C � T �' c��-� !z T%^ � v
Roofing Company Name: �/�� Z S�' �` � /z��C� 7=- i/� C.
Applicant's Signature: Date: /�`�7 C-- �' �
Greg Casteel
Building Official
Revised 11/2/04
� CITY OF �UPERTINO
2 ITEMS OF 2 PERMI�' RE�.'EIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN ......... 36�;01011.00
DATE ISSUED.......: 11,'26/2007
RECEIPT #.......... BS()00003321
REFERENCE ID # ...: 07:_10140
SITE ADDRESS .....: 21�E52 ELM CT
SUBDIVISION .......
CITY .............. CUl'ERTINO
IMPACT AREA .......
OWNER ............: BIIdO JACOB
ADDRE5S ........... 21�652 ELM CT
CITY/STATE/ZIP ...: CU]'ERTINO CA, CA 95014-4919
RECEIVED FROM ....: JA�7IER CHAVEZ
CONTR.ACTOR .......: TB]) - TO BE DETERMINED LIC # 00096
COMPANY ..........: TB]) - TO BE DETERMINED
ADDRESS ...........
CITY/STATE/ZIP ...: ,
TELEPHONE .........
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -�--------- ---------- ---------- ----------
1REROOFRES SQ FEET 21.00 273.00 0.00 273.00 0.00
BSEISMICRE VALUATION 8,500.00 0.90 0.00 0.90 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 273.90 0.00 273.90 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 273.90 VISA
---------------
TOTAL RECEIPT : 273.90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
605 FINAL REROOF
FROM : NELSON ROOFING & REMOVAL FAX N0. : 14082253229 Dec. 19 2007 03:53PM P1
�32� Sylvandale Aveuue �
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