15030168 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21371 MILFORD DR CONTRACTOR:CUPERTINO ROOF,INC PERMIT NO:15030168
OWNER'S NAME:
SAN JOSE,CA 95129 PHONE NO:(408)973-9427
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIALE]
TEAR OFF(E)WOOD SHAKE,INSTALL(N)OSB,LIFETIME
License Class C Lic.# COMP SHINGLE(31 SQ'S)
Contractor I)_a____ -- 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
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:$17000
1 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:32641102.00 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 DAYS OF PERMIT 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 DAY T CALLED 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 .3
granting of this permit. Additionally,the applicant understands and will comply e Y ate:
with all n - oint source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature Date =+G All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION ) —
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 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 Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod , and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: / Dat
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
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 21371 MILFORD DR DATE: 03/26/2015 REVIEWED BY: MELISSA
APN: BP#: *VALUATION: $17,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAMATION 1SFDWLROOF
USE: SFD or Duplex PERMIT TYPE:
WORK TEAR OFF E WOOD SHAKE INSTALL N OSB LIFETIME COMP SHINGLE 31 SQ'S
SCOPE
FEE ID ROOF AREA
s.f.
1 REROOFFRES 3,100
pw
01
r, a
Mcch. Plan Check Plumb.Plan Check flee.Plan Check
�1erh_ Permit Fee:: Plumb.Permit Pee: Glec. Permit Pee
Other iLleeA Insp. Other Plumb Insp. Li 01her Elec:.Insp.
A,Lch. Insp.Fee: Plumb. Ins/). Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the pre1hnWdna information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7ff /1/13) FEE QTY/FEE MISC ITEMS
Plan Cheek Fee:
:Suppl. PC Fee
1'lumlr✓1�:fe ch.11s'le.c
Permit Fee: $527.00
Suppl. Iq�ee I I ----T--=
Plum b./1fech.;�11'lec
f'(a�rnt�.i".�1c;c1.;1>lc'c Permit Fee:
Conslr'uction Tax:
Adinlnistrative Fee:
Work Without Permit? ® Yes (E) No $0.00
,ldvaneed Planning Fees:
Tr(4 gel Documentalivn.F`ees:
Strong Motion Fee: IBSEISMICR $2.21 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$530.21 0.00 T 2AI;FEE' $530.21
Revised: 02/14/2015