B-2017-1217CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1217
10366 MILLER AVE CUPERTINO, CA 95014.3426 (375 04 018) HOMEOWNER
BUILDER
OWNER'S NAME: TAYO OSCAR AND GILDA TRUSTEE
OWNER'S PHONE: 405/247-0199
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor HOMEOWNER BUILDER 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:
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.
I have and will maintain Woiker'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.
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 tobuilding 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 7/25/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
m. 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)
YOI, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code). i
I hereby affirm under penaltyof perjury one of the following three declarations:
m. 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.
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.
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
1 certify that I have read thisapplication 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 thej City of Cupertino against liabilities,,
judgments, costs,'and expenses which may accrue against said City in
consequence of the granting 'of ttiis,permit. Additionally, the applicant understands
and will comply with all non-poirytisource regulations per the Cupertino Municipal
Code, Section 9.18.
Date 7/25/2017
ISSUED: 07/25/2017
PHONE NO:
BUILDING PERMIT INFO:
BLDG —ELECT —PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
DESCRIPTION:
DOF; TEAR OFF; COMP SHINGLES (6 SQ)
Sq. Ft Floor Area: Valuation: $3000.00
APN Number: Occupancy Type:
375 04 018
PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT'IS'SUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Abby Ayende
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
inspec 'on.
$t afore of Applicant:
bate: 7 25 2 1
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 r devices which emit hazardous
air contaminants as defined by the Bay Area Alt Quality Management District I
will maintain compliance with the Cupertino nicipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 2 505, 25533, and 25534.
OWi"er or authorized agent: � f/
ate: 7/25/201
CONSTRUCTIONNDIN G 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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
REROOF PERMIT APPLICATION
its COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 - FAX (408) 777-3333 - buildinciAcupertino.o[q
PROJECT ADDRESSAPN
LICENSE NUMBER
LICENSE TYPE
BUS. LIC. #
9
E-MAIL
OA"
MILLE&
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PHONE
ARC[ JITECTiENIGINEER NAME
LICENSE NUMBER
BUS. LIC
OWNER NAMENE
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STREET ADDRESS'
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STREETADDRESS
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ITY, T E, ZIP I
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CONTACT NAME
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Provide copy of Manufacturer's Installation Specifications.
PHONE
I
E-MAIL
I
STREET ADDRESS
Provide signed copy of Cupertino's Tear -Off Policy.
CITY, STATE, ZIP
FAX
1 11 OWNER 11 OWNER -BUILDER 11 OWNER AGENT 11 CONTRACTOR 11 CONTRACTOR:AGENT 11 ARCHITECT 0 ENGINEER 11 DEVELOPER El TENANT :1
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC. #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARC[ JITECTiENIGINEER NAME
LICENSE NUMBER
BUS. LIC
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS'
CITY, STATE, ZIP
PHONE
USE OF 5/ SFD or Duplex C] Multi -Family
STRUCTURE: 0 Commercial 1
ROOF AREA:
5'&0 F:T_- T�
VALUATION:
31 OL90
IEXISTING ROOF TYPE: L (BUILT-UP ROOF 13 ASPHALT SHINGLES 13WOOD SHAKES C3 WOOD SHINGLES 11 OTHER (SPECIFY) I
REMOVE/REPLACE NrYES
❑ N.
I IF NO.
.# LAYERS
ordinances and state laws relating,lo building constrytion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
PLYWOOD
THICKNESS-
Erv", 1:1
1:1 5m.,
PLYWD El osB
TYPE:IT' C. Dx
PITCH:
I -
:12
ROOF
CLASS: A
PROPOSED ROOF TYPE: MBUILT-UPROOF
11 ASPHALT SHINGLES
11 WOOD SHAKES
❑ WOOD SHINGLES ❑OTHE R
ICC -ES REPORT #
IDESCRIPTION OF WORK.
nI N n1)r-)r-1kLt_- LAA -i -I --. L- I A L I C i R 'i I - r U 1, 1 VJL& 1 611F,!• 12.C?D 1: 7►1 S 4 A L � L -
By my Signature below, I certify to each of the following: I am the property owner or authorized agent t . o act on the property owner's behalf. I have read this
application and the information I have provided is cor)ct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating,lo building constrytion. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
b7 17
Signature of Applicant/Agent:
Date:.
SUPPLEMENTAL INFORMATION REQUIRED
If building is associated with a Horne Owner's Association, provide letter
'A
PLAN dtiz CtcTYeE
s RgUTINGSLIt'
of approval from HOA.
'PLAN RFVWV
Provide Planning approval to verify if there any restrictions.
Provide copy of Manufacturer's Installation Specifications.
4"
k
Provide signed copy of Cupertino's Tear -Off Policy.
ReroofAI)IL201 I.doc revised '03116111
CL PERTINO
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino_org
PROJECT ADDRESS
03 Lo Co .LLF L/ ILL CiU j2. 1lND
APN N 31S _ ��0 I Z
V
OWNER NAMEHON
E-MAIL
STREET ADDRESSt ie C kzeQ.7C
C Y. STATE, ZIJ7AP!ISD
At* / _0
25
CONTRACTOR NAME
LICENSE NUMBER
LICENSETYPE
BUS. LIC. 9
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
I UNDERSTAND AND AGREE TO THE FOLLOWING:
1. The re -roof project shall comply with all applicable provisions of the 2016 California Codes.
2. An inspection request can be scheduled up to one business day before the requested inspection date.
To schedule inspections 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 -6n the day of the
inspection only after that phase of the work is completed. The building inspector will be out to the
job'site within one hour. The hours for this service are: 7:3040:30am 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. 'fear -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 %" 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 re required to be installed in accordance with Sections R314 and R31 of
the 2016 California Residential Code. ,
of
ReroofP4Iicy_2014.doe revised 0601,
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildingCa,cupertino.org
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 ADDRESSLit / '
10--3&& ► fell w� /u
APN
2M - W-012
BP#
OWNER NAME q /
OWNER ADDRESS
,0^ '
DESCRIPTION OF WORK:
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.)
�i- I 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 ownlabor 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 in',surance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the .iimits of my
insurance coverage for injuries 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.
3. 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. ;
iT4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�5. I 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" understate and federal law.
i
6. I 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
e to serious financial risk.'
7. 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 bl/ work, is !performed by
licensed subcontractors and the number of structures does not exceed four within any caleln'daryea;r, ;or all of the work
is performed under contract with a licensed general building Contractor.
8. I understand as an Owner -Builder if I sell the property for which this permit is issued', jl may be; held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any !atent,cohstruction
defects in the workmanship or materials. i
OwnerBuilderFornzl 2010.doc revised 04/14/10
f y; : . 1 .
�f9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California,Department of Benefit Payments,
and the California Division of Industrial Accidents., I also understand I Imay contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
ontractors.
i
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
I
�F11. 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.
p
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws 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.
I
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
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
i 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 accepts /e to the city may be required to be presented when the permit is issued
to vedfv the prooerty owner's sianature. , i I
Property Owner's Signature: �/b-NyJy : Date:j 07.1,7,5-11:7-
(NOTE: The following Authorization Form is required to be completed by�'the properfy owner only wh; en 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:
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 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 property owner's
signature.
Property Owner's Signature:
Date:
I
I
i
Owne7Buildel FOrn1 2010.doe remised 04114/10