15100201I CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 20642 CHERYL DR I COSYSTEMSRACTOR: WESTERN ROOFING I PERMIT NO: 15100201 I
OWNER'S NAME: JEROSZKO EDWARD T AND FREDALEN 11328 WHITE OAKS RD I DATE ISSUED: 10/26/2015 I
OWNER'S PHONE: 4082573024 CAMPBELL, CA 95008 1 PHONE NO: (831)278-1837
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
TEAROFF WOOD SHAKE ROOFING, FILL SHEETING AS
License Class Lic. # NEEDED ,INSTALL DUPONT ROOFLINER SYNTHETIC CLASS A
UNDERLAYMENT AND THEN INSTALL A STONE COATED STEEL
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:
i. 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.
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.
APPLICANT CERTIFICATION
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
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 pen -nit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature
Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
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
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
i. 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.
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.
3. 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
APPLICANT CERTIFICATION
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
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
Date
Sq. Ft Floor Area: 0 1 Valuation: $16000
APN Number: 35916022.00 I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
1\11\It►NI I1 PI V! 101111.N'l DH 'AN1 M[:N'I' - BUILDING DIVISION
CUPERT tNO 1 IO tli-\ IORRi AVi NVI: • t:UP 1"1INO, 0A 91,)014-:3255
t-tL\;t\ ; i i ;y `: ;1 FA\ ON)'; li- 33, - hufldiitil�?rutu�llino_,tarc� / ` / 0 0
�-� 1D- �C (1.O ,1'erin't No. �J �/
Skip the rest of the form and sign bottom of form.
%10 `: atioil !.
that, due to the age or Con [1gllydtl0(1 Of the proJ�IVED
in.s'aI,_t;:0 n -.I, o C-':011"CI\IIIg 1111inYhlEU; Rxttire s is not tecllnicaIIy feasible?
i i\ a �'.':: tions ] 10 1. tln\u h 11111,\ do not apply.
i, t }:,
''.;: li: c:l:e.l 1`lunli`.:t''s ccitiliclltioll has been provi ed to the Building DivisioIl.
::. t of (h: fonii and sign bottoni of forum.
u for your builditlge.
Co'le Sc: t.Ons 1101.1 through 1101.5 do not ripply. Skip the rest of the form and sign bottom of form.
;S \ .`t�`^: :\ b:..:i .n13 3\'ail3blr for use tlr Occlip nhGj= on Orb: fore January 1, 1994?
`�:\ Ni'," ani \;Y la's 1 1 r
.. x a i , le for use u' occthgul� 1 I?mien January 1, 1994.
.' \ : t',,:c �ccli.'l:s 11111,1 tluou�h 1 li\i.S do not apply. Skip the rest of the form and sign bottom of form.
\ c ;\ :Z-a'z available for use or occupancy on or before January 1, 1994.
1101.1 through i I O1.S appy, Check one of the three following statements and sign
a res:',,.:FJl real property. See Ci -61 Code Section 1101.4.
<�n a . a:i'er : n1. _0144, building alterations or improvements shall require all non-compliant plumbing fixtures
'a, \\ :u. \\at, Cnscr\ ng Plumbing mixtures throughout the building. On or before January 1, 2017, all non -
shall be replaced with water -conserving plumbing fixtures (regardless of whether
inaproveirents).
:v res"", lt..:?real Pr ptn\� See Ci\i1 Code Section 1101.5.
n.',itlecy bullduLgalterations or improvements shall require non- compliant
;� 'e . .eu a •, \\'a:er :or.en in` Plumbing fixtures.
1%.":rWi 14 ' it Ila`:::l`:il"1'.3rti plYunbl ng fixtures shall be replaced with water-
...th.%.- gho t the building (regardless of whetherproperty undergoes alterations or
ty. See Ci\il Cede Section 1101.5.
_':14, s^c.:tied bu;'.diig alterations o: in Yrovenlents shall require non- compliant
\ : ,; ., .,cd w'dl wal,r onsening pl_a bing fxtttres.
':: a:• _ o zo-opli nt plumb:ng fixtures shall be replaced with water- consen ing
(rega,dle S of \Q',-:h,r property undergoes alterations or improvements).
. 3: • { :'\.; ": ,, -- c a ::::''f this po rt\ c tnifv ander kt13 t1' -if pejL>r-�' 1113E I pl
r- _ non-compliant utnbing fixtures will be
% sprTd a!N \: N; L \\'3ter-co : er\ing p:>L:mbhfig fixtures in accordance with CIVil Code Sections 1101.1
al
co'c - ahf"'T';a Green Building Standards Code, and tn�..nt-
..acturer's
g ^' �.: t• :� _,\: re`s comply \\irh the requirements as indicated In tilt
`,-
Date %J
��' '�` �:'� +'•.••.:sty. E "e3 rCka'i"' ' :Re In order to .Inial your bu".13ng permit.
WOKI 'ARHON MONOXID1 Al. ARMS
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OWN( 14 Ct 141 It 1(,-,A I FOf GOMPtIANCA-
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]it dwt,111111" 11111k with no con-imercial pL)11,'Cl- SLIPI)ly, alarni(s) iiwl\ bL' "011-1y
lit 111,11111,11-c permitted tob(-st)lelybattery (il)eriteLI where rcpairsor liltur,.ition, d,
j 1110 W111OV,11 ()I NV,111 MILI ceiling finishes or there is no acc(-'s by illeans, of attic, basement or CTaWl'l
( l,k' 1014 and ('13C S(Tliom 907.2.11.4 and 420.6.2. All ch'ctmal permit 1,., required for
L-()IllleCtt-(l to tilt' L)Uildill)." wiring.
A, (Of the al-ttwe-referenced property, I hereby certify that ffie alarin(s) referenced above hasfhavebeeli
if Kkord,ijice with the manufactilrer's instructions and in compliance with the California Building
.1114 ( 1111h)IIII'l Posident),111 Codes. The illal-ins have been tested and are operational, as of the date signed
bel()w
I have read and agree to comply with the terms and conditions of this statement
7;Z ; (or -oww Aowwro Name:
. .. ....... Date:
Z_ Signature.. . .. A/V)
(.antractar Name
Sionature... ... ...... .............. . ...... . . Licitit ......... ......... Date: ............... ...
smoke and (.'Oformdoc revised 03118114