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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
�CONTRAGTOR'hIIVFOLtMATION a
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5u1LDINGADDRESS:
WAGNER ROOFING CONTRACTORS
S?'T"04050037
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
(408)777-8331
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
li d under provisions of Chapter 9 (commencing
I hcmby affirm Nat 1 amft an
with Section70xM) of Division 3 of On Basinen and Professions Code,end my license is
in fon fortemndcflor
2p� �p tt
' G'7L Z
REROOF 11—ti11 @'1�f�C�ME®
Liccnw Co., Lb. p
Dale / /^ " Contractor f
ARCHITECTS DECLARATION
o
II / 'IOoAY
MAY1 1 I L
I understand my plans moll he uwd'u public me..
Licensed Professional
OWNER -BUILDER DECLARATION
T (I n�B sw�
I h,mhy affum that I am exempt from On Canvoemr's LLccnsc Law for thc
®ypll
I��U L INN
BUILDING
following mason. (Section 7W 1.5, Business and Profession Cody Any city Or count,
ve, demolish. r mPair anY structure$9765
which require a permit to conswct, elle/Busi
prior w its issuance. also require the applir such permi rile a signed statement
Nat he is licensed pursuant On Provisioe Contract s UemsC Low(Chapm 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Divisithe Busi s and Profession Code)tar
that he is exempt therefrom and Nebasis aIle exemption. Any violation of
35APNIR &13,00
Occupancy Type
Section,?031.5 by any applicant for a perects c applicant to a dull penalty of
not mom Nan five hundred dollarI,ssown,r
of the property, or my empith wages as theirvele comanntion,
Required Inspections
will do the work and On mucture is not imof oRmm to, sale(Sac. 7066. Business
and Profcomes Code: The Conuacmrs law don not apply m an owner of
property who Wilds orimprove Nemon, a doessuchwork himselfor through his
own employee. pfovidcdNat such improvements are not intended or offered for sale. If,
however, On building or ient is sold within one year of completion. Ne owner -
mprovem
builder will have the burden of provinS Net he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, sm'edusively contracting with licensed mmncton to
comouct the project (Sec. 7614. Business and Npfculon Code:) The Contractor's Li
cons, law does not apply w an owner of property who build or improv Nemon, and
who contracts for such projects with a eumrwmr(s) licensed pursuant to the Contractors
License U-
0 1 am exempt under Sec . B & P C for this moon
Owner Dale
,
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the following declartions:
1 have and will maintain a CCNficam of Consent to self -insure for Workers Compcm
whoa, u provided for by Section 37M of the labor Code. for the performance of the
work for which this permit is issued.
❑ 1 hove and will maintain Worker's Compensation Inwnnce, az required by Section
3100 of the labor Conic. for the performance of Ne work for which Nu permit is issued.
My Workers C m rad n Inwn,,rrc/e ,artier and Policy number am:
Carrier. 5 �a"� Policy No.:I001> 200f
CERTIFICATE OF 'XEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(loissection need not be completed if the permit is far one hundred dollen (11 W)
or less)
I certify Nat in the performance of the work for which this permit is issued, 1 shall nm
employ any person in any manner an u no become subject o the Workess'Comromamon
Laws of California. Dam
Applicant
NOTICE TO APPLICANT If. after making 06 Cenificate of Exemption, you should
become subject to the Warhvs Compensation provision Of Ne labor Code, you must
forthwith comply with such NUOSInns or Nis Permit shall be do med revoked.
CONSTRUCTION LENDING AGENCY
1 herby affirm Nat Nor is s lending agency for the performance of
which ed (See
Nc work for which Nis permit u issued ISec. 309], Co, Cd
I.emers Name
� 1<ndr's Addres
1 certify Nat I have read this applies.. and stat, that the shove information is
-
cornett 1 agree to comply with all city and county ordinances and state laws relating to
Wilding convection. and hereby oulhotir representative of this city reenter upon the
above-mendnmd property for inpcetion purposes.
(We) agree to gave, indemnify and keep harmless On City of Cupertino against
liabilities,judgments. casts and expenses which may in any way scene against said City
in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date O
SOURCEREG LA ONS.
�1'`�`t� —
Re -roofs
Type of Roof
Signature ApplicanUC,ntrwmr a—�
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harudous motorist
az defined by the Cupertino Municipal Code. Chapter 9.13. and the Health and Safety
Code. Ouyes is332(a)]
All roofs shall be inspected to any roofing material being installed.
No
prior
Will the applicanfor future building omrpant tau equipment or dcvicn which
Fruit
If a roof is installed without first obtaining an inspection, I agree to remove
hazardous air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
DisuirO
❑Yes No
I how mad Neaardnemamdals requirements under Chapter 6,95 of the Califor-
nim Kmit&Safmy Cade.Stt on35505.35533wd M5 .1undcrsmndth ifft building
t
does trot su nmly have a knmL Nat it u my mspomihili y to mrtify the necupsm Ne of
![urs
requirements which nun E. met pd owisusuccoracIcniricakof Occup ey.
�'9 pplicaW - Date
#eC^ 7
All roof coverings to bess "B" or better
Adhori7cd
Owner or agent tic
IC
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRES /// /J /
(��•�
PE #v D 3-70 -3 7
ME
OWNER'S NA: 4W,i
PHO »7- 335"
GENERAL CONTRACTOR: / - H
FAX It
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
9---�� w-1 'C `\CVQ
e /tr
Conactor ignature
b 0"ri
D to
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 TaA
Sheet Metal
Sheet Rock
Tile
9---�� w-1 'C `\CVQ
e /tr
Conactor ignature
b 0"ri
D to
INO rtm
Building Depaen
Community Development
't 10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
t
JOB ADDRESS: 771 r PE # L/T
OWNER'S NAME: `W L fl PHONE- '777-"3
FAX #
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the followinginformation:
Date
SUBCONTRACTOR
BUSINESS NAME
GENERAL CONTRACTOR:
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the followinginformation:
Date
0 ne'./Contractor`S'ignature
t
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
r
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
f,
Plumbing'
Roofing 4
Septic TarY-
- -
Sheet Metal
Sheet Rock
-
Tile
�.
0 ne'./Contractor`S'ignature
t
CITY OF
UPEkTIN®
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Building Department
Subject: Re -roofing policy for the City of Cupertino
Telephone: (408) 777-3228
Fax: (408) 777-3333
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:
Job Site Address:
Roofing Company Name: R OPo a �iN rO"V 7f, 7,4-1
c
A plicant's Signature:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Date:
CUPEI�TINp
APN # ,S 3
Address.
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o.v Y H.'!/S
Name: M2 C ti tiNh
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/Contra+ -
P•D. /3,x 353' 3 rho.✓e �:..�
%,JL i IK vr' CUPERTINO
REROOF o ,�
PERMIT APPLICATION FORM
Contact:
Job Dy-YrlWI1O
1i10n: 'Per+rovf Sh.f/.� /1�✓ Z'NS{,t //
Resldenual: 40 ya u S '%" c ,cV �; CO
Sq.Ft. Floor Area ?moo , , y � � f.
AtthitecUFngincer. �� 99
Phone #:
License #: 6 719 Z $•
Phone #
777-833>
Fax #: 777- b'3�3
9,
BPERMFEE
BENERGY
rce txscn tion
Bld Permit Fees
Ener
Fee Group
BUQ.IDNG
BUU-MNG
BSEISMICRE
BSEISMICOM
Seismic Fee Res
Seismic Commercial
BUHMNG
BUU
DNG
BPLANCHK
Plan Check Fee
BUILMNG
BUSLIC
Business License
BUUIDNG