15040070 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23505 OAK VALLEY CONTRACTOR:KENT ROOFING PERMIT NO: 15040070
COMPANY
OWNER'S NAME:
CAMPBELL,CA 95008 PHONE NO:(408)971-4042
Eg'' LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
RE-ROOF 38 SQ;TEAR OFF ROOF SHAKE, CLASS A
License Class (, -'> Lic.#
ContractorkQ/Vv� ;Zlgs 9Coate
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:$25000
I 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:34257047.00 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 DA F 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 DAYS FR ST CALLED INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signaturesull,� Date 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.
-I OWNER-BUILDER DECLARATION
Signature of Applicant:
hereby affirm that I am exempt from the Contractor's License Law for one of
he following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
,as owner of the property,or my employees with wages as their sole compensation,
vill do the work,and the structure is not intended or offered for sale(Sec.7044,
lusiness&Professions Code)
,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
onstruct 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
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
eclarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
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
ompensation,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
rformance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
ave and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections
ction 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent:
unit is issued.
ertify that in the performance of the work for which this permit is issued,I shall
t employ any person in any manner so as to become subject to the Worker's
mpensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
come 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
hwith 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
rtify that I have read this application and state that the above information is
ect.I agree to comply with all city and county ordinances and state laws relating
uilding construction,and hereby authorize representatives of this city to enter
n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
emnify and keep harmless the City of Cupertino against liabilities,judgments,
ts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
ting of this permit.Additionally,the applicant understands and will comply
all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
iature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 23505 OAK VALLEY RD DATE: 04/08/2015 REVIEWED BY:
APN: BP#: "VALUATION: 1$25,000
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION
USE: pPERMIT TYPE: 1 SFDWLROO
WORK [RE-ROOF 38 SQ'TEAR OFF ROOF SHAKE CLASS A
SCOPE
FEE ID ROOF AREA
S.f.
1REROOFFRES 3,800
rdv?.4ti4 " tom.w}""�
Mech. Plrari("heck Plumb. Plan(heck Elec% Plan(`heck
F1eela. Permit Fee: Plumb. Pem;t Fee: Elea. Permit Fee:
Orher Hech. [rasp. FI other Plumb Insp. Oiher Insp.
Mech. [tup. Fee: Phimb. hasp. ree: Elec.Insp. Pee:
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 prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS(Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Pe',e:
.SuppI. P('P'ee
Plztmf�.;'';t 1ec11.;'Z:lec
Permit Fee: $646.00
s1q.)pl. Imp Pee
Phan Llttecla.ilslec
Pla�nalz!rLlech.;`lslec Permit Fee:
Construction Tax:
Administrative Pee:
Work Without Permit? ® Yes 0 No $0.00
Advanced PlarmingPenes:
TrM,el Documents hm Fees: A
Strong Motion.Fee: IBSEISMICR $3.25 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
rqgg - _ $650.25 $0.00 T $650.25
e
O FEE:
Revised: 04/01/2015