14040069 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22545 KINST CT CONTRACTOR:XTERIA CONSTRUCTION PERMIT NO:14040069
OWNER'S NAME: MARY HASTINGS W TRUSTEE PO BOX 5460 DATE ISSUED:04/11/2014
OWNER'S PHONE: 4082529708 SAN JOSE,CA 95150 PHONE NO:(408)289-5353
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
16 SQ'S-REMOVE ASPHALT SHINGLE& INSTALL NEW
License Class e^ ✓?Cl Lic.#7 � ASPHALT COMP CLASS A SYSTEM
Contractor ±that
�– Date `–
I hereby affi �am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
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. Sq.Ft Floor Area: Valuation:$6900
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:34251007.00 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 relating WITHIN 180 D T 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 D ALLED 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 Date:
granting of this r i. Additionally,the applicant understands and will comply, ssue
with all non-poin rce regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date y—�r All roofs shall be inspected p for to y roofing material being installed.If a roof is
installed without first obtaini inspection,I agree to remove all new materials for
inspection.
13OWNER-BUILDERDECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.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 y Ar Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 0 2 ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
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 CONSTRUCTION LENDING AGENCY
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 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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,
Signature Date
RER I OF PERMIT APPLICATION
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La COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION A
10300+RE AVENUE•CUPE TINOI CA 95014-3255
(408 77117-3228•FAX 408 777- 33• •uildin cu ertino.or
CUPERTINO } ( } b aCa� D a
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PROJECT ADDRESS i1 L � f it APN*: � Z � � l D Q
$,OWNER NAME ' �^� G�_ PHONE Z E-MAIL
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STREET ADDRESS �,STATE,ZIP
CONTACT NAME
0 PHO E-MAIL ('
4 i7 7�37��
STREET ADDRESS ►TY,STATE,ZIP FAX
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OWNER ❑ OWNER-BUILDER ❑ 4NERAGEN'T �NTRACTO ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ,dp LICENS NUMBER LICENSE TYPE BUS.LIC.# 2L-.7 J T L,
COMPANYNAME V�- MAIL FAX
rlo�.. � ION �-Gere •.�.c LI
oC5 7/6
STREET ADDRESS ITY,STATE,ZIP PHONE
555 ar`,4,Ew 13 Situ rbsc ysr�G a8 ��S�T77
ARCHITECT/ENGINEER NAME I LICENS NUMBER BUS.LIC.
COMPANYNAMEE,RAIL FAX
STREET ADDRESS i rTY,STATE,ZIP PHONE
USE OF SFD or Duplex f❑ Multi-Family R F AREA: VALUATION:
STRUCTURE:
El
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EXISTING ROOF TYPE: ❑BUILT-UP ROOF ASPHALT SHINGI 10 WOOD$HAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
RENIOVE/REPLACE YES IF NO. I PLYWOOD ❑ vi- El._ PLYWD ❑ OSBPITCH: ROOF
❑No THI s: ❑s ' TYPE: ❑ CDX :12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF PHALT SHINGLES WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT m
DESCRIPTION OF WORK:
e o f J
I
By my signature below,i certify to each of owing: I am the proowner or authorized agent to act on the property owner's behalf I have read this
application and the information 1 have pro co t 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui I authorize rep tsentati.ves of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:
Date: 7�`/
s -
SUPPLEMENTAL INRMATION REQUIRED OFtCI� IY y.
_.If building is associated with a Hgme Owner's Association,pi ovide letter ' Ito[i SLIP
of approval from HOA. ' AN`P -
BUMMINGPLIEH
_Provide Panning approval to veru if there any restrictions. rEw
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Provide copy of Manufacturer's Itstallation Specifications. FtlzxDpT
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_Provide signed copy of Cupertino' Tear-Off Policy. "` 1 oTHfiR
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I RemofApp_2011.doc revised 03116111
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CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22545 KINST CT DATE: 04/11/2014 REVIEWED BY: MELISSA
APN: 342 51 007 BP#: *VALUATION: $6,900
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1SFDWLR00
WORK 16 SQ'S - REMOVE ASPHALT SHINGLE & INSTALL NEW ASPHALT COMP CLASS A SYSTEM
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 1,600
s 3 +
Plan f'luwh, I'/cm Check 1'i`��z:.I zn C k,'clr
a1�tc;it. T'> rrtaf��c>+ Phimh.l'e;mit7�`ee ( `<"r �.rraitF� c:
C3/7r�r :Wech. Insp. Other Plumb Insp, Li U/hur 1 `ec.Insp. Ll
h. M 11" 1' '(': Phd lh. hid)). Fee: 1;i<'f'.In4p,,"'O
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addh7 info,
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
lCZ '
(,heck 1<ee,
SuPpi. PC Fee
Permit Fee: $256.00
l'irtrsif7;'t f<r,'',.i >tec' Permit
Con,.�ts'trction 1 IXI
(rlrrlrrtr.�tr't7tf.'L.'t`'E'£':
Work Without Permit? ® Yes No $0.00
,Iol YdrPcet l Plaroling Fes:
Strong Motion Fee: IBSEISMICR $0.69 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
_ LS:; $257.69 $0.00 TOTAL FEE:` $257.69
k .
Revised: 04/01/2014
I
u REROPF TEAR-OFF POLICY
COMMUNITY DEVELOPMENT D PARTMENT-BUILDING DIVISION
ALBERT ALVADOR,P.E.,C.B. .,BUILDING OFFICIAL
CUPERTINO 10300 T , RE AVENUE CUPE TINO,CA 95014-3255
(408)77743228-FAX(408)777-3333-WIdingCt_cupertino.org
3
PROJECT.4DDRESS APN4 3.,L( 2
OWNER NAME 6I F-Ztf G\ -z " E-MAIL
9
STREET ADDRESS { � CITY,STATE,ZIP FAX
CONTRACTOR NAME j LICENSE N 1 LICEF 3`TYP BUS.LIC.
is z-ZDq �23q-4
COMPANY NAME MAIL G+�" 715 Z-57-1
STREET ADDRESS L� C Ty,STATE, A C PHONE
1'Yra+ ,ZIP } -Z C �/" 7f�7 " Z95 7777
I T�NDERSTAND AND AGREE TO THE FOLLOWING:
1. The re-roof project shallcomply with all applicable provisions of the 2013 California Codes.
2. An inspection request can be scheduled up to one business day before the requested inspection date.
Please schedule inspections online or call (4 8) 777-3228 from 7:30-3:30pm (Mon-Thurs) or 7:30-
2:30pm (Friday) to schedule inspection. Fo Tear-Off and Nailing Inspections, you must also call on the
day of the inspection onl� after that phase of th work is completed. The building inspector will be
available within one hour. The hours for this service are: 7:30-10:30am and 12:30-3:30 (Mon-Thurs)
and 7:30-10:30am and 12:30-2:30 (Friday). Final Inspections will be given a two hour window.
3. Tear-Off Inspection is required. Any and all.dry-rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked-down or removed pri r to'this inspection.
4. If plywood is installed, aplywood NailingI s e±ction is required.
5. Roofing shall not be applied without first o aining all prior inspection 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.
b. A Final Inspection and Approval shall be btaned from the building inspector when the re-roofing is
completed. To receive alfinal sign-off, the f Dllowing items will be verified:
a. Flat roofs shall have a minimum of %"per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing age cies.for all pre-manufactured products used shall be
available on-sits to review at the tirne of the inspection.
c. Proper spark arrIpstor installation, vents painted, gutter/downspouts installed, debris removed.
7. NOTE: If you call for a dear-off or plywood nailing inspection and the work is not complete, you will be
charged a re-inspection fee. The re-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. I unde4tan d gree to co ply with the re-roof policy stated above. I also understand that
smoke detectors and carbon monoxi a et rs are re uired to be installed in accordance with Sections R314 and 8315 of
the 2013 California Residential o
Signature of Applicant/Agent: Date:
RerogfPo1icy_2014.doc revised 01115114
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