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03100057 CITY OF CUPERTINO - 9adxr>x'tl BUILDING DIVISION PERMIT � CON,TRP,CTQRINFOrRMATItON BUILDING ADDRESS: GROMO ROOFING PERMIT NO 03100057 OWNER'S NAME: 121 W WASHINGTON AVE . PERMNISSUEDATE NE: (408) 746-2075 SANITARY NO. CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH X00 LICENSED CONTRACTOR'S DECLARATION lb Description iY 1 herchy affirm that 1 am licensed under previsions of Chapter 9(commoner or ng i< wWSrcli�on 7(IfllBaf Divieion3ofthe Bassi and Pmfcuions Code,end my license ie < in full�pka vndpffec1� S'qz Ucntfe2lwe•�y" is _ I,asJSOTT e/ _ REROOF SIC fnrL co r .� ARCHITECI'SDmcomo O� 1 undmrnanJ my plans shall be used u ¢rnrsB public /�/wY`/ i dal '0 Licensed Pmsai fcnnel 1 OWN E-BUILDER DECLARATION l0 F 1 hcrchy,(Gere on IE.I.S.exempl from Ibe GONraClCo License Law for Ibe th O following inmost.(Section 71Dconstruct.aims and ve. wino Cooc:Any ciy nr courtly f$ which its issuance. sss s permit us itheeller,iaprove,demmuln or repair any tamctuin f" that hefts issuers pursuant to the inions of the for suchCon PermitufleseLaw(ned staumcm sS< (commencing encinnsedPun7 theprevivinu.foftheStrinessanianulaw(Cheplar9 Sq.Ft. Floor Area Valuation 2 $ (coma,is e.g with Sectionfvor and MbssDivision r the itis alleged axe pt on.Professions Cale)or 11 that he u exempt Therefrom end Ne buts for Ne alleged eumptlon.Any violation of Section 7031.3 by any applicant for a permit subjects the applicant to acivil penally of APN Number Occupancy Type not...Nan five hundred deltas($SW). ❑1.uownaofthepmpeny,mmyemploy withvngesu Noirsoleeompemtim, will do the workmd the atraCuse is not intended oroffmad for mle(See.IDN,Business 3 0 5 — L.' Ty and Professions Code:The Canuaci.e.License Law does not apply to an owner of an307 - INSULATION Inspections property who Wilda or improves thercon, d who deeswch work himself or through his own employees,provided that such improvements arc nCllntended oroRered for aid,If. 601 — ROOF TEAR OFF however,the building or improvement is old within one year of completion,the owner- builderwill MveNeburdenofproving that hedid not Wild Orimprove for purpose or 602 - ROOF PLYWOOD NAIL sale.). ❑ I,as owner of Its Property,am reclusively contracting with licensed contractors to 603 - ROOF BATTENS construct the project IS".7(0q Business and professions Code:)The Contractor's L4 604 — ROOF IN-PROGRESS come law does not apply to an owner of property who Wilds or improves thereon.and who contracts for such projects with a contractor(s)licensed Pursuant o Ne Canl,ect.r a License Law. ❑1 am exempl under Sec. .B tk P C far This mason Owner Dau WORKER'S COMPENSATION DECLARATION I hereby affirm under Penally of Perjury one of the following declarations: I have and will maintain a Canlficote of Consent v selGinmin for Worker's Compere 13700 on,u provided for by Section 3700 of the labor Code.for the Performance of the k for which this Permit is issued. 1 have and will maintain Worl eM1 Compensation Insurance,u inquired by Section of the labor Code,for the performance of Ne work for which this permit is luued. WorkeesCommosafonlmumncecanfCfapd Policy number art: rice tY'OT r FY/.a-b Pot yNo.:T4 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (iris section need not becornpleted lithe permit Is rate=hundred dollen($)W) .,less.) 1 certify that In the performance of the work for which this permit is issued,I shall not employ any person in any manner an as to become subject to the Workers Compensation Laws of California.Data Applicant NOTICE TO APPLICANT':IL after making this Cenificate of Exemption.you should become subject to the Worker's Compensation provisions or the labor Code,you most Oforthwith comply with such provisions or this Permit mall W demand invoked. y y CONSTRUCTION LENDING AGENCY I hereby affirm that them is construction lending agency for the Performance of 3: the work for which this permit H issued(Sec,3(y97,Civ,C.) Y0 Undoes Name 3.z l�nder'sAddreas 0 1 certify that 1 have read this application and sou that Ne show info rroa on i, y F correct I agree to comply with all city and county ordinances and stale laws reining to DUbuilding construction.and hereby authorihe mpmsenudws of this city m enter upon Ne Ya shove-mentioned property for inspection purposes ti (We)agree to save,indemnify and keep harmlw the City of Cupcnino against fA IiaNlides,judgments,costs and expenses which may in any way acme against mid City / J,Z in conuqueace of the gramme of this Permit l APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date SOURCE REGULATIONS. Re-roofs alurc ofAPPlicanUConlnctor Dau HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding usupant mom or handle huudous materid u defined by the Cupertino Municipal Code.Chapter 9.12.sed tbe Health and Safety Cock.Seale.xssl:(.)7 All roofs shall be inspected prior to any roofing material being installed. Yu we WIII IhCepPI ma,ortWamhullJiagaC[.panluW C(IulPlnenlafdmVl[G WIIICII If a roof is installed without first obtaining an inspection,I agree to remove it haurdous air contaminants as defined by the Bay Arca Air Qua ily Management all new materials for inspection. wart, `f ❑Yes 6Nu Ihe.temlthehr.artious Sectors 25505.25533umcntsun Iudromad.95 oft,Wilding nixs ualdr no,..rSdm Code.Sectors25505.25533I,I myrmens334,1 to near, toff J.Ca nal curten0y how a serene that it is my rcspomihilily m nodl'y tbe cupmt of Nc myuircmentswhich LWmetpriorit)hortmesofaccNBcao:ofOccasacry. Signature of Applicant Date ��wnAll roof coverings to be Class"B"or better cr or aah.rlrcd goal Date Community Development Department Building Division City of Cupertino A 10300 Torre Avenue Telephone: (408)777-3228 CITY OF Fax: (408)777-3333 UPEkTINO 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: ! f n t K/f T i✓E/C Job Site Address: II X'77 CO//'FA Pl R /f 6 Roofing Company Name: A plicanYs Date: • Greg teel Building Official Revised 1/30/03 Printed on Recycled Paper CITY OF CUPERTINO v 3 �S REROOF CUPEI�TINO PERMIT APPLICATION FORM APN# 3 b G sal/L �S / Date: Building Address: 7` T 1/.S"77 c�P/'E.0 rPnlyt Owner's Name: Phone#: JfA / J-1z - 27,V0 Contractor: Phone License#: C/do 2,0 7S Contact: Pho a#: Cupertino Business License#: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles p Asphalt Shingles §r 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: s119ir4r Pv7`D4' 0f-O 4 ti 7W 1 F! SO yr//ic <vti0 lT11! Residential ❑ Commercial ❑ Fire Zone: Yes ❑ No ® Confirmed with Plan; there are any restric Cost of Project: Type of Con!7W• Occupancy group: rovv. - Qty. if Applic 1 Fee ID Fee Description 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 z3 lo7. sD