04030060 CITY OF CUPERTINO p `w
BUILDING DIVISION PERMIT �SCONTRA.CTOR INFORMATION :
BUILDING ADDRESS: 1111N004030060
OW NER'S NAME: PERMR L95UE DATE
LUPE
ONE: SANITARY N0. CONTROL NO.
ARCHITE MNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
L O'z LICENSED CONTRACT'OR'S DECLARATION O O O O
I bucby sRrm the,I am Removed unacr provisions of Chapter 9(commencing Job Description
with Secomr tn(Xn of Di,nom 3.1'the Business and Professions Code,end my license is
^e m in full force and effect.
513z License Class I.ic.g FINAL INSPEC.ONLY FOR INSPEC .DONE 4 YR. AGO
Z;:0 Date Contractor
tj' ARCHDECrS DECLARATION
IDI undersand my plans shall he used b re
public cords
''o Licensed Profuaionel
5 OWNER-BUILDER DECLARATION
<Z I hereby.(firm that 11. cacmps Item the fictions one License Lew for the �®
i pe O following mason.(Section] ossu Busmen and Pe.dere l Code:Any city m county
structure which its issuance,
a Pcrmio re c.nsvuc4 alter,impmsu dsermit t fie a sig any ttnsctum
prior bat its issuance,ossa nt to the she applicant for such Permit m files signed statement ly
?< that me cing wit Pursuant.she provision of the eBonn=Andxnx Law(C odc)or Sq.F[. Floor Area on
J!R
(commencing exe exempt
Sitio. and
ddo Divisiofr the
NCBuilnexmpton.fAnyvi Code)or
.• that he u exempt sAny Applicant
li and the per for be ctsft exemption.Any violation of rJ 2 y 8 8
Semon7031.5than five
stry applicant fora permit subjects the applicant to a civil Penalty of APN Number T e
not more man Bw hune.e nonan(SSW). � Y YP
1,d,owner of the Progeny a is nploycu wise wages r then sole compedauon,
will neo mesion,and the stmContrarot i Limen ma w do fs not apply toad,Business
And Profession,caac:Tne Contractor's cave Law dors not apply m an owner or Required Inspections
property who builds or impmw thereon,end who daaueh work himtelf m thmugb his
own employees,provided thatsueh improvement,are,not intended oroRemd fmsak.If.
however,the building or impmwment is cold within one year of completion,the awner-
builder will have de,burden of proving that he did not hold or improve for purpose of
sale.).
El 1,as owner of the pmpeny,am exclusively contracting with licensed contactors to
comsrocs the project(Sec.70a,Business ana Pru(esm.Code:)'Dte Coin cbh U.
cone law docs not apply.an ownu of property who builds or improves thereon,and.
who conmem for such projects with a conmc.r(s)licensed pursuant on the Contractor's
Law.
6�11 nm tempt under Scc. .B&P C far this mason
spam 3 la O
WORKER'S COMPENSATION DEC ON
cbyaffirmunder p
affirmenalty of perjury,one of she following dalantions: _
1 have and will maintain a Cerufiam of Conant to aelf-insure for Worker's Compct.
ation,u And
for by Section 3]00 of the LAW,Code.for nee performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as requited by Suction
37W of the Lmor Cods,forme performance of the work for which this Permit is Lsmeo.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rDsuaectum need notWmampleted lithe Permit is(mane hundred dollars($100)
or Ica.)
1 modify teas in the performance of the woh for which this Permit is issued.I shall nos
employ any perste in any manner se a to become subject to the Warken'COuOxmSaion
Law.of California.Dam
Applicant
NOTICE TO APPLICANT:IL alto,making this Certificate of Exemption,you S1muW
become Subject in the Worker's compensation previsions of this Labor Cadc,you most
.J z foMwith comply wise such provisious or this Permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
1 hereby arum that fere is a construction C mlending for Ote p derma cis,of
a.)the work for which 6 permit is tossed(Scc.3091,Civ.C.)
G Undcr'u Name
Le
.7 z nders Aanm..
O Q 1 codify that I have rid this application and state that the abuse infomNon u
coma 1 agree W comply with all city and county ordinances and Alan,laws relating to
0U building conduction,And hemby authorize rcPrcsenmives of this city.color upon the
N W ahovc (We).ed Property fm inspectionnifPurposes
F a (WC)agree b neje,indemnify Of thus Na iL hamlet'fie City Of Cuperlllln agtin5l l! —'�.I WV /
Vj
liabilities.judgments,costs and expenses which may in any way same against aid City
U z A mnamPLICuenee ofdtegrantingof this permit. Issued by: Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL/NON-POINT
SO EGUL N�TI(1-SAI [t
IJ/(YJGJ—� 3 c Re-roofs
Si ler of ApplicanUC.mracmr pry
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
L
ll the apPlimns or future Wilding occupant tom m handle haallous material
u defined by the Cupenino Municipal Codc.Chapter 9.12.and me Hcalth and Safety
ode.semen zs,33(a] All roofs shall be inspected prior to an roofing material bei.
❑Yes L>� P P Y g g installed.
Will the applies.,o,fund.building..,art sax equipment m device which If a roof is installed without first obtaining an inspection,I agree to remove
..i,Disvha oodnus air mmandirmnu�ur ticoncd by ft Bay Area Air Quality Management all new materials for inspection.
❑Yea n
C
I haw&Sem thehandouts25 r5.n533rements 5534.1 rChageull ft ofthc Califing
nine Helm&Safety Dads.Secdmu 15505.33533 uW3353a.1 undesatatm thsi(Ne building ba �O,I
Jarcurrentlyncurrently haw•tomo,that i,is my msponsibili,y to tmdfy the axupant of the t/Vttt///����"'www""TT"'NNNN S/a
regi. cutswhich.YsIMcon'intoauanccaf.CCdlnCateorocupiey igna re of Applicant Date
o rte tnhmi,edagcm D,te All roof coverings to be Class "B"or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U���,,,,,I�O Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
• 3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: Cop"- two '6yocovk ��wes�ncw i GC(lQa/rpQ LA p
Job Site Address l04 SS 77V�Ue
Roofing Company Name::
A phcant's Signature: Jam �• �o KOY Date:
I
Grego
eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
t REROOFCITY OF
CUPERTINO PERMIT APPLICATION FORM
APN At 3 2� 33 o Z-
Building Address:
10L{SS �a�ndl Di iuv
Owner's Name: Pho a#:
Mo) 32s-�6oa
Contractor: Phone#: License#:
Contact: Phone #: Cupertino Business License#:
J�w�bJaU�,r 2eWfcl a, �,�ev Cyoe) ase-lzsa
Type of Roof Covering:
Existing: Proposed:
X Built-Up Roof >( Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description: .� I!P al �t
Residential ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any r stri tions: LJ
Cost of Project: Type of C s do Occupancy gro
Qty. if
A li ble Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees MBUILDING
BENERGY Ener
BSEISMICRE Seismic Fee Res
BSEISMICOM Seismic Commercial
BPLANCHK Plan Check Fee
BUSLIC Business License