B-2016-2875 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2875
19624 HOMESTEAD RD CUPERTINO,CA 95014-0607(316 05 047) DAN ELLIOTT'S
ROOFING COMPANY
SAN JOSE,CA 95159
OWNER'S NAME: GOOD SAMARITAN UNITED METHODIST CHURCH DATE ISSUED:10/06/2016
OWNER'S PHONE:408-605-4504 PHONE NO:(408)559-7327
LICENSED CO ',CLARATION BUILDING PERMIT INFO.
License Class ROOFING Lie.# 16 1338
Contractor DAN ELLICITTS ROOFING COMPANY Date 01/31/2017 X_BLDG _ELECT _PLCTMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
MECH—RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL OSB;COMP SHINGLES(60 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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. Sq.Ft Floor Area: Valuation:$16008.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,.and hereby authorize 316 05 047 .
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
` Additionally,the applicant understands and will comply with all non-point
source regulations per the Cuperti unicipal-Eode,_Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/Signaturel)(.c�.'d`� Date 10-6-2016 Issued by:Kim Dunbar
Date: 10/06/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. L as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business-&Professions Code). Dater10-6-2016
I hereby affirm under penalty of perjury one of the following three declarations: AT•T ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the;Cupertino Municipal Code,Chapter 9,12 and the
Health&Safety Code,Section 25532(a)should I store or handle hazardous
s, 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 material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. 6.-wner or authorized agen
APPLICANT CERTIFICATION Date:10-6-2016
1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertinoagainstliabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 10-6-2016 Professional
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333-building@cunertino.o[g
4�1PERTINQ `(�) g)
PROJECT ADDRESS (� Q"",-A � � APN#
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STREET ADDRESS CITY,STATE ZIP FAX
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Q OWNER 1 OWNER:-BUMDER 1E OWNERAGENT ❑CONTRACTOR ❑CONiRACTORAGENT 0. ARCHLIECT 0 ENGINEER ® DEvELOPER 13 TENANT
CONTRA ORNAME � LICENSE f FSt LI LY/PSE BUS.LTC
COMPANY NAME
E-MAIL
_a FAX
STREET ADDRESS c� � a CITY,STATE ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MATE FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ® Commercial Q
EXISTINGROOF TYPE: ❑BUILT-UP ROOF EI ASPHALT SHINGLES O WOOD SHAKES ®WOOD SHINGLES U OTHER(SPECIFY)
REMOVElREPLACE YES 1F N(1 PLYWOOD " d PLYWD OSB PTT£Ii: ROOF
13 No #LAYERS: Tm ss- 13 5/s" TYPE: ❑CDX 2 CLAS ." A`
PROPOSED ROOF TYPE: O BUILT-UP ROOF 10 ASPHALT sHINGLES ❑WOOD SHAKES O WOOD SHINGLES O OTHER ICC-ES REPORT#
DESCRIPTION OF WORK:7pC 44 �L�
1 <- 1 j i G-Aai p 11 7
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behaL. I have read this
application and the information I have provided is correct. I have*' ad the Description of Work and verify it is accurate. I ogre--to comply with all applicable local
ordinances and state laws rely' _ ding c tion. I autho'w representatives of Gupertina to enter the above-identifiedgf property for inspection purposes.
Signature of Appli—t/Ag Date: � "J 0
SUPPLEMENTAL INFORMATIG"EQUIRED 41iiCz use owls.
If building is associated with a Home Owner's Association;provide letter PLAN xc� rac:sr '
of approval from HOA. fl:0VER�T.HE,—MTNTzR CQ '�ui�sairl r,�Ni r
Provide Planning approval to verify if there any restrictions. L; ., ❑ PLANNING PLAN REVIEW
Provide copy of Manufacturer's Installation Specifrcations. }3 [ "DEPT
Provide signed copy of Cupertino's Tear-Off Policy. ® alit
ReroofApp 2011.doc revisedO3116111