14100065 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1115 ELMSFORD DR CONTRACTOR- BB—Ti3--BE PERMIT NO: 14100065
ED
OWNER'S NAME:
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL
License Class C'-3 Lic.# q�-3o(, � '3 '9
RE-ROOF 35 SQ-TEAR OFF,INSTALL 1/2 OSB CLASS A
y�
Contractor ��C t v t'C �FbVtP�Date
I hereby affirm that I 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
mpensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000
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:36208009 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXP S IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITFIIN 80 DAYS PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned p e for inspection purposes. (We)agree to save 180 DAYS LA T CALLED INSPECTION.
indemnify and keep h ss the of Cupertino against liabilities,judgments,
costs,and expenses w ch ma" gdrue against said City in consequence of the /a I
granting of this pe it. A4 `ignially,the applicant understands and will comply Issued by: Date:
with all non-poi sour (cations per the Cupertino Municipal Code,Section
9 18.
tt / /to
EQ S:
Signature Date�� l l All roofs shall be inspected pr' y ofirig material being installed.If a roof is
installed without first obtain'1rg an}n ec on,I agree to remove all new materials for
inspection.
ElOWNER-BUILDERDECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROO CLASS"A"OR BETTER
1,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Scc.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) Id 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 94mlintelif or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the aaA
uality Management District I
performance of the work for which this permit is issued. will maintain compliance with th Cuicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti s 2and 25534. jJ
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
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 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1115 elmsford dr DATE: 10/13/2014 REVIEWED BY: Mendez
APN: BP#: 'EVALUATION: 1$20,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or DuplexL PENTAMATION 1SFDWLR00F
USE: p PERMIT TYPE:
WORK re-roof 35 s
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 3,500
I'lan Cha€. 1'htruh. I'lon Check P/an(,heck
Ve",;/L Petrrail Fee: Plumb. Permit Fee:
C}rtre,r'-icc Tr. 7r{alr, Othex-Plurnb Insp. Lj oMer 1"r°
t'ho0. hast). Vee: IEiec. If�sr.
2�L]
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the relimina information available and are onl an estimate. Contact the Det or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
I,C. 1'('
P ti'PiZ7
Permit Fee: $595.00
CCottst,'tic tion Tax:
r1E i, tr71 t/"CXttl'e'Poe:
Work Without Permit? 0 Yes No $0.00
��CZ i"iXiiC'L'U l't�LtYl117Yi�?`1`t"'£'s:
I i~<xel 11r>.°tcmeaalati art fees:
Strom Motion Fee: IBSEISMICR $2.60 Select an Administrative Item
Bldp,Stds Commission.Fee: IBCBSC $1.00
„ $598.60 $0.00 ° TOTi L FEE: $598.60
Revised: 08/20/2014