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CITY OFCUPERTINO
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BUILDING DIVISION PERMIT�0®�'�•��
x .'. es l ° 74-W-6,
BUILDING ADDRESS:
PERMITNO.
COSMOS ROOFING
OWNE
PERMIT 155
1901.OLD-MIDDLEFIELD WY
REdTER JE.
SANITARY N OL N0.
(415)493-6373
ARCHi cr(ENGINEER: -
BUILDING PERMITINFO
'
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm Nat I em licensed under pmvisiou of Chapter 9 (commencing
p
wise Section7000)of Dlvhion 7 of 070 Business and Profo+Nmu Code. And my lkonsn It
full ratchs. e/ G
in full t
F. �S 9�
.
L Clans Lt..,
REROOF
O
Date ARCHIIRCI'SDt ECLAR IDN
p
T/0 B. U. R W/GRAVEL, ADDBBgJ"(RAJ/ L
1 understand my phu mail he used As Public record+
- MAY 0 g 2003
Licensed Pod a..a'
OWNER-DECLARATIONBUILDER
m
1 hereby affirm that 11. eumpe from the ConinstCc :cense law for the
(Swim IIOL4 Boat=a and ons Code: Any Illy m county
whichmgmoon.
are. de
which requima • permit to enmtruc4 alar. Improve. demolish, lir repair any ttrumure
priorm itsissuance,Shurequire theapplic forthe Co permit L01ew Law mmmem
the (Chapter
Sq. Ft. Floor Area
aluation
o
that hairlicensed punASm 7000) provWsio of
a Business ankcnselaw
odc)or
(Commencingwith Section of oftaeeged Business and Pro( culrnrCade) or
bods for
titer he h exempt therefrom and dm bah ler tie alleged exemption. Any violation of
and
APN Number
- O upancy Type
Section loris by any Applicants fora permit eobjects the applicant 70 a Civil penaRy of
not mom than Bve hundred dolhn (5500).
❑ I, An owner of the property, or my employees with wage, As Orcir Sale compensation.
17qn4nnQ nn
Required Inspections -
will do the work. and the nuucmre is not Intended orCBertd for ASIA (See. 70", Bust=,
and Proreatons Cade: The Conuamots :cense law d= not apply man Owner of
prepenywho builds orimpown,themen.,ndwhhdoeuuchwarkhimselforWmu{h his
305 - 'FRAME '
own employ=, provided thataueh improvements art mnimcMed ararterW forsale.IL
however. the building or Improvement is sold within can year of completion, the owner.
307 — INSULATION
build.will have the burden Of proving Nat he did Am build m Improve for purpose of
601 ROOF TEAR OFF
-
❑ I, as Owner of the property am exclusholy contracting with licensed con annon to
602 - ROOF PLYWOOD NAIL
cmuwet the pmjm(Sec. Toa• Business and Prefe nos Code* The Contramrl:-
603 – ROOF BATTENS
come Law dean not apply to an Owner of property who buiid+or imprower Merton, and
who Contracts for such projcch with a comacur(0 licensed punento the Contractor's
604 - ROOF IN -PROGRESS
License law.
❑ I am ecmpt under See. . B k P C for MIS r)unn
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
bew and will maintain, Certificate of Consenter self-Inum for WarkeM1Compno-
an, u provided for by Section 5700 of On Labor Cade. for the performance of the
went Tor which this permit is Issued.
1 haw and will maintain Woneh Compensation Insurance, u required by Section
71 of the labor Code, for the performance of tee won for which this permit is Issued.
My WOrket, Com on con=,liter ted PolicYCnumberare•
MycarW. tr Policy � f �7—//2,
'
CERTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis wedon need not be completed if the permit is forone hundred dollen (S 10()
lir WA)'
1 cenlfy that In the performance of the work for which this Permit is issued. I+hall not
employ any person in any manneru as to become subject 70 tho Worems' Compcuation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: Jr. arm, making this Certificate of Exemption, you should
became subject to the Wortsr'a Compensation Provisions of the lalwr Code. you must
foMwlth comply with such provisions or this permit shell be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby 1111. that then is a ccrutrocdon lending a{ancy, ren the performance of
the work for which this permit Is issued (Sec. 3097• Co. C.)
Lender's Name
Lender',Address
-
1 certify tial l haw mad this application and scum that the above information is
correct. I agree to comply with all city and county ordinances and Sum laws relating to
Wilding construction, and hemby authodn representatives of this city to enter upon the
ahove•memioned pmperty for Inspection Purporns.
(We) agree As raw, indemnify and Scp harmlw the City of Cupertino against
1labillde, judgments, costs and expenses which may In any way accrue against Said City
In conseque= of the granting Of Chia permiL
APPLICANT UNDERSTANMNNN000IScc�RAAAAND WILL COMPLY WITH ANON -PAINT
Issued by: Date
SOURCE RECULATIO -g _,J
Re -roofs
Type of Roof
e3
Sitnuure ofApplicandConusem �—
HA2ARD0 S MATERIALS DISCLOSURE
Willy no umaterW
_
the CummirmfMuni Municipal e. Chapter , and the Health
u dcMW by the Cupertino Municipal Cada ChePmr 9.@, and me Heatth and safety
-
Cade.Sectionus7z(.)7
All roofs shall be inspected prior to any roofing material being installed.
oyes I
If a roof is installed without first obtaining an inspection, I agree to remove
Ynti me appnem ser mart building aecppam am equipment or dcmnB which
it hasudnus air comammom; see dc0 by the Bay Area Air Quality Management
all new materials for inspection.
Point?
❑Yes Nu
I haw read tier haASrdtmsmaterhh requirements under Chapor6.95 Cline C lifor
niaHulN@SafmyCode.Secim25505.]5573and25534.1u rv=dthatifthebuilding
does not curren0l haw a tenant,• thht it la my mapoulhlllly m reqtif[yp tcis uecupant M sec
6�
,
rcyulrt a et bcmm er70issuanre Ofa Omitmnmd pney7
Signature of Ap licant Date
T, /�
All roof coverings to be Class "B" or better
Owner or authoikked agent one
,
CITY OF
CUPEkT1NO
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
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: 620, � Att,_e..�>
Job Site Address: 19
0
Roofing Company Name: (-_-ate
A plicant's Signature:_ a Date: 1 0 3
Greg teel
Building Official
Revised 1/30/03
Printed an Recycled Paper
J
CUPEI�TINO
CITY OF CUPERTINO 0 3 a 3 G
REROOF
PERMIT APPLICATION FORM
APN # 3-25-0q—co
Bldg Permit Fees
Date:
Building Address:/?5G 3
a�:ce,�i tw
Owner's Name:
Phone #:
S"S� Co
BUILDING
BSEISMICOM
Seismic Commercial
Contractor: Phone #:
BPLANCHK
License #:
65v 9419-7663
qv/
Contact: V CPhone #:
BUILDING
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
Built -Up Roof
`91- Built -Up roof
Cl 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 #
ATo be Removed
C1 Provide Mfgr. Instailation Specs.
I Have Read, Understand and Will Comply With Cu
a ino's Tear Off Policy:
Job Description: T o rl
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planning Deft. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
S;2- G O . SU
Qty. if
AnDlicable
Fee ID
Fee Descrintinn
Fee Gmnn
/ BPERMFEE
Bldg Permit Fees
BUILDING
BENERGY
Energy
BUILDING
/ BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING