05070040 CITY OF CUPERTINO vane ,
BUILDING DIVISION PERMIT �CORTRACTORANFORMATION$'
BUILDING ADDRESS: FOUR SEASONS ROOFING PERMITNIb5070040
OW NER'S NAME: PERMIT ISSUE DATE
PAVEL RUBINSHTYN 502 HORNING
NE: SANITARY NO. CONTROL NO.
(408) 278-0330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I�
X00 LICENSED CONTRACTOR'S DECLARATION IF.0 ,/l
uF 1 boreby affirm that I am littnud under provision of Chapter 9(commencing Job Description, /J r
_ZW wiNSection]OOU)of Divivion3 of NC Basin=s and ProfcssiunsCode,and myliccnm is W✓ pp
mmnmreeanae a REROOF W/SHINGLES
p Z LiccnuC CLic crp
E g O Dato Cu heeler di
ARCHITECTS DECLARAION
T
,9
3� 1 understand my plans Nen W tried M Pants,records
30 ; Licensed Professional
g 3 OWNER-BUILDER m Ce Contractor's
E<0 I hereby maso .Sect on 1 am exempt from Nc lessmcmr's a Any c Law for the
5 O O following reams Peon t ](13 L5.Business and Profadonx Crede:Any oily or tructucounty
m which regmr=a Petit nt emmswn,aloe improv,hdemolish,Pe tu or repair any atmmere
_Zy Paths inissuance.
sedismmm to the the appinso for me uefmitwfilc Law(sutemcm
< WlWulianwJPurstion7NWProviviousnoftheBumws;andcnussimCodur9 Sq.F[. Floor Area " �Valua[ion
z
(commencing exempt therefrom
and
Division J oftWBedexe andon.myansCndc)tar
i�$ Net he u exempt therefrom and dmc beau for the alleged exemption.My violation Of
Section 7031.5 by any applicant for a permit mbjecu the applicant to a civil penally Of 361Q Q Occupancy Type
not more than five hundred dollars($500).
P y yp
I]1,as Owner of the property,in my employees with wages As their sole compensation.
will do the work and the swcwre is not intended in offered foresle(Sue.7041,Business
and Professions Codc:The Conracton License Law does not apply to an owar of Required Inspections
popeny who buildsm improves thereon,and who doessmuhwork himself or through his
own employes,provided Out such improvements are mtinrended m offered for sale.If.
however.Ne building or imprvemern is to within me year of completion,the owner-
builder will have the burden of proving that As did nam Wild or impmw for purpose of
sale).
❑I,as Owner of the property,am=elusively contracting with licensed contractors to
construct Ne pmjen(Sec.7044,Business and Pofrssions Code:)The Contractor's Li
cons'Law does net apply in an Owner Of property wW Wilds or improve]Ne2on,m0
who contracts for such projects with a emtmctor(s)liceomd pursuant to the Contractor's
License Law.
❑ I em exempt under Sec. B Ar P C For this meson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pmully of perjury ane Of the following decuretiom:
I have and will maintain a Certificate of Consent to self-insure for Worker's Contras
cation,az provided for by Section 3]00 of LAIR, per
e lJr Code,for Ne perforans or Ne
work For which this permit is issued.
Ave and will maintain Worker's Compensation Insurance as required by Section
of Ne Labor Code,for the performance oldie work for which this pemtil is issued.
My Worker'sOComPennti==ean/ie� Policy number ares: ,n
Carrijr. IW/NtL L_Y6Ii,No.:W CO-"�W0000'
6 L CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
l'MfscTtiNmrneed Out he completed if the permil is interim hundred dollars(5100)
M1 M1as.)
1 certify Nal in the performance of the work for which this permit is issued.l shell ml
employ any person in any moor so as in become mbjeet to the WOrkeri Compensation
Laws of Calirorm Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate Of Exemption.you should
become subject to the Workers Compensation provisions of Me Labor Cnde,you most
,,. ,Z forthwith comply with such provisions or this Permit shall he deemed revoked.
z CONSTRUCTION LENDING AGENCY
[� Ihereby affirm that Nem is a connrection lending agency for dte performance of
the work fur which this permit is issued(Sec.3097,Civ.C.)
UJ 0 Lendcea Name
Z)2 Lender's Adel
U Q 1 certify Net 1 have read Nis application and stat,that the a Wvc information is
fa.F COMM.l agree to comply with all city and county ordinances and sure laws minting to
0U building conswnian,and hereby authorixerepresenutives of this city to enter upon lW .
r� above-mentioned property for inspection purpoxs.
(, n' (We)agree to sen.militarily and keep harmless this City of Cupertino against
V3 liabilities,judgments,costs and expenses which may in any way across against said City
U in consequence of Ne granting of this Permit.
'—' APPLICANT UNDERSTANDS D CO LY WITH ALL NON-POINT Issued by: DateG-
SOURCEREGULATI
��
Signature OfA,11115 Re-roofs
anUCommclar te
HAZARDOUS M RI LS DISCLOSURE Type of Roof
Will the applicant, fuusrt W' in uproot nom of handle hLLdous mawrial,
As defined by the Cupeno Municipe oda Cbepter 9.12,and the Health And Safety
Allikonar.castYors zssJ2(')7
es All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building=upon(use equipment or devices which If a'roof is installed without first obtaining an inspection,I agree to remove
it ha/atoms air contaminants az dcrined by rte Bay Area Air Quality Management all new materials for inspe ion.
Vial? e
YCa
I have mail the M1aaardnuxmaterialsmyviremcnts under Chapter 6.95 of Ne Calif.,- �/
C
alif.,-
me Health&Safety Code,Secvons 25RI5,23577 anJ 25734.1 undersand Nat iflW Willing
es not currently have a tenant,Na is my meremobility to runty Ne occupant or the
uimmcrt w rest m noruissupme.r.Cmtificneafoi,,d.cy. Sig Lure ofAppli nt Date
ner or Irud agent Cil' Da.. All roof coverings to be Class"B"or better
awor
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOBB ADDR$SS: / n PERMIT # OYD�UO4 O
(("/ (U �nL
OWNER'S NAME: S//V PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEI�TINO
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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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:
Job Site Address:
Roofing Company Name: 44Z
Applicant's Signature: Date:_14�6J
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
alTy REROOF
CUPERf INO PERMIT APPLICATION FORM
�S'-1.2_ ,-12_ -
o �O Date:
9— .�
Building Ad
Owner's e: Phone i{:
jon
ctor: Phone #: Lie sca:/
cv o i'
Phone Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
Q ' Wood Shingles /' ❑ Wood Shingles
X Other(Specify)t,��' IKpoe. ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report 71
❑ Tobe Removed ❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With .Cu ertino's Tear Off Policy:
Description:
s t
kol
4-
Fee
Residential Co rcial
Fire Zone: Yes ❑ No Confirmed ��.ith Planning D,�ept. if
there are anv restrictions: uCost ofProj�ct: T of Co ction: Occupancy 'group:
o0Qty. if
ID Fee Descri tion Fee Group
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
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