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B-2017-1401CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1401 6080 WILLOWGROVE LN CUPERTINO, CA 95014-4649 (375 38 019) COSMOS ROOFING OWNER'S NAME: DICKINSON JAMES O JR AND CHRISTINE J OWNER'S PHONE: 408-257-3904 LICENSED CONTRACTOR'S DECLARATION License Class= Lic. #785441 Contractor COSMOS ROOFING INC Date 04/30/2019 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: 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 41permit 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 permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 8/22/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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) 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: 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. 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. 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 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 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 8/22/2017 INC MOUNTAIN VIEW, CA 94043 ISSUED: 08/22/2017 PHONE NO: (650) 969-7663 BUILDING PERMIT INFO: X BLDG —ELECT _ PLUMB MECH X RESIDENTIAL COMMERCIAL JOB DESCRIPTION: RE -ROOF; TEAR OFF; 4 PLY TAR & GRAVEL;- (26 SQ) Sq. Ft Floor Area: I Valuation: $13260.00 APN Number: Occupancy Type: 375 38 019 PERMIT EXPIRES IF WORK IS NOT STARTED . WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Jasmine Archbold Date: 08/22/2017 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: 8/22/2012 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. Eor authorized agent: el: 8/2212017 RU T OJJE%A�ENCY I hereby affirm that there is a constructs n ending 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) .777-3228 • building@cupertino.org PEMIT Of. CUPERTIN0 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION ❑ T.I. ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA PROJECT ADDRESS 0 o III J O (JL^ APN ti —6^ 5 n Y PHONE � _q '-NAMESk 5 1 EMAIL STREET ADDRESS <R0 0111006LiJ CITY, STATE, ZIP 1c_0p1,z-7 A 9 501 4 ZJt- (,J n G CONTRACTOR NAME '❑ OWNER -BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE COSMOS ROOFING 785441 C39 STREET ADDRESS CITY, STATE, ZIP 1901 OLD MIDDLEFIELD WAY #4 MOUNTAIN VIEW, CA 94043 E-MAIL PHONE BUS. LIC # 650-969-7663 ❑ ARCHnECr .❑ OWNER ❑ OWNER AGENT Jj'CONTRAcroRAGENT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTACT' NAME E-MAIL JEFF RAINEY' jeffrey.rainey@att.net STREET ADDRESS CITY, STATE, ZIP PHONE, 1069 EDGEMERE LANE HAYWARD, CA 94545 510-785=6340 DECRIPTON ,J7 1/r� 12i — �hZ �C� ITA-%z-,�__ ,/2C_ Ip- /rk)c INSINGLE FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL USE TYPE OCC SQ,FT.. ,VALUATION ($) LEXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES k I 0 Ak JTOTALNETSF REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ ATTACHED I BATHROOM SF SF SF SF ❑ DETACHED EXISING❑❑ NOS FIRE SPRINKLERS EICHLER ❑❑ NO SECONDSTORYADDITION ONO DWELLING SECOND DWELLING ❑ YES ❑ ATTACHED ❑ DETACHED OTHER UNITS # UNIT ADDITON: ❑ NO SF I POOLS ❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED A k -11 , POOL - SF SPA - SF SPA ATTACHED ❑ YES ❑ NO TOTAL - SF NED BY: , j TOTAL VALUATION. Commercial or Mul&Familu Buildings with Public Swimming Pools requires Department of Environmental Heath avnroval - 13. 260 RE -ROOF EXISTING ROOF TYPE: ',BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ TILE OTHER (SP CiF1� REMOVE /REPLACE ❑ NO IF NO PLYWOOD ❑z ❑ 3/8" PLYWOODTYPE: PITCH " :12 ROOF CLASS YES # OF LAYERS THICKNESS ❑ 5/8" OTHER% L ❑ OSB ❑ CDX OTHERAA A PROPOSED ROOF TYPE: BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER i *Provide a signed copy of the Cupertino's Tear -Off Policy SFS , hof SQUARES By my signature below I'certify to each of the following: I am the property owner or authorized agent to act on tli'e'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 itis, accurate. I agree to comply with all applicable: local ordinances and state laws relating to building construction. I authorize representative's of Cupertino to enter the above -identified property for inspection purposes a and authorize all information contained ori this' application form' to be made available for pubhrecord. Signature of Applicant/Agent: SUPPLEMENTAL INFO ONIREQUIRED *New SFD/Second Dwelling Units/MultifArr l el . �?.olition permit is required prior to issuance of a building permitkfor all new, constriction. *Commercial Buildings: Provide a complete azardous Materials Disclosure form if any Hazardous Materials are being used; a5. part of ithis project. *Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. *HOA -Provide a letter of approval from the Home Owner's Association B1dgApp_2017 doc'revised 08101117 CUPERTINO REROOF TEAR -OFF POLICY 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 / © 1 l 16 1J G i II SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION GUPRT1NO 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333• buildinq(a cupertino.orq PERMIT C NNOTBE FJ] ALED UNTIL:MS:CERTIFICATE HAS BEET MP' LETT B,SIGNED,ANIS RETURNED "C TIE 8 ;3i :3 I S1(flN PURPOSE This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2016 CRC Section R314,2016 CBC Sections 420 6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000 00, CRC Section R314 and CBC Sections 907.2.11.5 and 420 6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations. AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of X X the bedroom(s) On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that do not have an attached garage Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420 6 and shall be approved by the Office of the State Fire Marshal. Power Supply. In dwelling units with no commercial power supply, alarm(s)may be solely battery operated. In existing dwelling units,alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl space.Refer to CRC Section R314 and CBC Sections 907.2.114 and'420 6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above-referenced property,I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes The alarms specified below have been tested and are operational, as of the date signed below 4- Address- (giOSO 6�if9 //0 1 i-ov i! �P �sa�a, A 9 01Permit No.13-2-0/7— /40/ Specify Number of Alarms: #Smoke Alarms. J .S #Carbon Monoxide Detectors j I I have read and agree to comply with the terms and conditions of this statement Owner(or Owner Agent's)Name: , Signa ure . .V. r(��/�/./ Date: Contractor Name: Signature Lic.# Date: Smoke and CO fonn.doc revised 12/1.5/16