15100101 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:CITY OF CUPERTINO PERMIT NO: 15100101
OWNER'S NAME: CITY OF CUPERTINO 21979 SAN FERNANDO AVE DATE ISSUED: 10/13/2015
OWNER'S PHONE: 4084601821 CUPERTINO,CA 95014-2823 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
BLACKBERRY-POOL BUILDING-TEAR OFF(E)COMP&
License Class Lic.# INSTALL(N)CLASS A COMP ROOF SYSTEM(20 SQ'S)
Contractor 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: Sq.Ft Floor Area: Valuation:$0
1. 1 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 APN Number:35710008.00 Occupancy Type:
performance of the work for which this permit is issued.
2. 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
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITH_IN 180 YS O RMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 1 ALLED INSPECTION.
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 ent
upon the above mentioned property for inspection purposes. (We)agree t I y: Date:
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 with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ROOFS:
All roofs shall be inspected prior to anyy roofing material being installed.If a roof is
Signature Date installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
%D OWNER-BUILDER DECLARATION Signature of Applicant: ate:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF C 'RINGS TO E CLASS"A"OR BETTER
the following two reasons:
1. 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the
2. I,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
1. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2. I have and will maintain Worker's Compensation Insurance,as provided for by O or authorized agent: /
Section 3700 of the Labor Code,for the performance of the work for which this Date: (�`
permit is issued. /77
s. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
upon the above mentioned property for inspection purposes.(We)agree to save
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 with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature t r-- Date '' b: 0o
REROOF PERMIT APPLICATION
0 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333•buildinc0-cupertino.orcl
� f !,(J f U
PROJECT ADDRESS APN#
ltj4f, - 1 o � O
OWNER NAME'` PHONE J E-MAIL
STREET ADDRESS CITY,STATE,ZIP 6 1 FAX
CONTACT NAME U PHONk E-MAIL
O '.
STREET ADDRESS �r CITY,STATE, ZIP FAX
S
❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMF, LICENSVNqB FB LICENSE�TYYPE BUS.LIC.#
VaAk- rb
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial no
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YES IF NO, PLYWOOD ❑ ''/w, ❑ PLYWD ❑ OSB PITCH: ROOF
❑ NO #LAYERS: THICKNESS: ❑ 5/8" TYPE: ❑ CDX '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT#
DESCRIPTION OF WORK:
67
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By my signature below,I certify to ear of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatingt ilding construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 1-
SUPPLEMENTAL FORMATI 'N REQUIRED OFFICE USE ONLY
If building is associated with a Home Owner's Association,provide letter PLAN CHECK TYPE ROUTING SLIP
of approval from HOA. ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW
Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD ❑ FIRE DEPT
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
ReroofApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 21979 SAN FERNANDO AVE DATE: 10/13/2015 REVIEWED BY: MELISSA
APN: 357 10 008 BP#: VALUATION: Iso
°`PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY Commercial Building PENTAMATION 1 COMMLROOF
USE: PERMIT TYPE:
WORK BLACKBERRY - POOL BUILDING - TEAR OFF E COMP & INSTALL N CLASS A COMP ROOF
SCOPE SYSTEM (20 SQ'S)
FEE ID ROOF AREA
s.f.
1 REROOFCOM 2,000
j:[rL'h. P/tttl Owl
I-iawil..11.1.an t heckC'C I'la t
Alech.Permit Fee: Niatih. PerTnit Fee: Elee. Permit Fee:
Other Nfech.MIT. Other Ph.onth 1tzv), 0ther I:lec. fnsp.
AlcJc°lt. h7s��.Fee: I'lt�frth.I�zsp.I' lJec.
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1113) FEE QTY/FEE MISC ITEMS
Plctn Check Fee:
.571ppl. PC Fee F-1
P.nnb.IA,tech./Flee.
Permit Fee: $394.00
Sttppl. Insp F'ee
P11unb.Heel./F._:lec
P1umb.1A,1eeh.1 lec Permit Fee:
C'onstr'uction Tax:
Achninistr ath(l,Fc�c�:
Work Without Permit? 0 Yes 0 No $0.00
1c11>uncc�c/f'1c7t7ftirt;Fees:
Tr•avvl Doc uinentcztion Fees:
Strong Motion Fee: 1BSEISMICO $0.00 Select an Administrative Item
Bldg Stds Commission Fee: $0.00
SUBTOTALS: $394.00 $0.00 TOTAL FEE: $394.00
Revised: 10/01/2015
REROOF TEAR-OFF POLICY
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR, P.E.,C.B.O., BUILDING OFFICIAL
C U P E RT I N O 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•building cupertino.org ( G
1669 10 1
PROJECT ADDRESS ` ✓ APN# �'']� U
-21 q Z
OWNER NAME O ` PHONE E-MAIL
C
STREET ADDRESS CITY, STATE,ZIP FAX
CONTRACDNA14E r LICENSE NUMBER LICENSE TYPE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
I UNDERSTAND AND AGREE TO THE FOLLOWING:
I. The re-roof project shall comply 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 (408) 777-3228 from 7:30-3:30pm (Mon-Thurs) or 7:30-
2:30pm (Friday) to schedule inspection. For Tear-Off and Nailing Inspections, you must also call on the
day of the inspection only after that phase of the 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 prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining 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.
6. A Final Inspection and approval shall be obtained from the building inspector when the re-roofing is
completed. To receive a final sign-off, the following items will be verified:
a. Flat roofs shall have a minimum of I/"per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre-manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
7. NOTE: If you call for a tear-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 understand and agree to comply with the re-roof policy stated above. I also understand that
smoke detectors and carbon monoxide detectors are required to be installed in accordance with Sections R314 and R315 of
the 2013 California Residential C e.
Signature of Applicant/Agent: Date:
ReroofPolicy_2014.doc revised 01/15/14
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228• FAX(408)777-3333• build ino(c.cuoertino.org
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at: -
SITE ADD S - _ _.._: . ... .AP
� 1 or
O AME OYJNcR ADDRESS:
DESCRIP 10N OF WORK: 0 a I a s
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
P24 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those icjuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for inaries to workers on my property.
�2. 1 understand.building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
93. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
444. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
49—/—5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law,
g6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
07. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
a8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
aa,nerEuilderForm 2010.doc revised 04/14/10
A_-9. I understand I may obtain more information regarding my obligations as an "employer„ from the Internal
evenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or v,vnlr.cslb.ca.gov for more information about licensed
contractors.
4-6.10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand thatam te party legally and financially responsible for proposed construction activity at the site address listed above.
�11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
62. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l have-provided on this form. Licensed contractors are regulated bylaws designed to protect.the.public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a.result of a complaint,-.Your only remedy against unlicensed
Contractors may-be in civil court. It"is also important for you-to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit.as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the ro ert owner's si22ftLe.
Property Owner's Signature: - Date:
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(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the proper,l owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwnerBuilderForm 2010.doc revised 04/14/10