03090182 CITY OF CUPERTINO ,
BUILDING DIVISION PERMITCONTRACT(IRINFORMATIQN
BUILDINGADDRESS: COSMOS ROOFING PERMIT N003090182
OWNER'S NAME: 1901 OLD MIDDLEFIELD WY PERMUISUEDATE
3
NE: (415) 493-6373 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
C=
�Oz LICENSED CONTRACTOR'S DECLARATION
I I Mrcby afOrm Thal I em licensed unJer provision of CNpor 9(commencing Job Description
With Section 7=))o(Division 3 of the Bmincaand Pr E.end mylicena i.
10 a force one cc 7 • REROOF
m 2 Licenu C s Lic.
Darc
C ARCHrtE S DELI. ATION r !QJ/
f W< I undairmail my plans shall M..it aspublic rernNs �S/�j.�
S G� Licensed Professional —\7
OWNER-BUILDER DECLARATION
xI 1 Mrehy affirm that Item exempt from On Contracture License Lew for the
00 following reason.(Section 7031.5,Business and Profession Code:Any city or county
<$� which requires a permit to construct,alter,improve,demolish,or repair any suamure
�Zi• prior In its issuance,also requires the applicant for such permit to rile a signed statement
< The,Mislicensedpam...ItotheprovisionsofMeCohuecmr'sLicenseUw(Chspc,9 Sq. Ft. Floor Area Valuation .
(commencing with Section 7")of Division 3 of IM Business and Professions Cole)tar
Nat he is exempt therefrom and Me basis for the alleged exemption.Any violation of 36204054 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of APN Number Occupancy T
not more then five handled dollars(5500). - p y ype
'--'
01,As an,of the property,or myamployces,with wage..that,vele compmalion,
will do Ne work.and Me structure is not intended proffered for sale(See.7W,Busineu — gg��yt�Ir�d
and Preressiom Codc:The Contralore Llama Law Ones not apply to an owner of 3 07 — INSULATl VN Inspections .
progeny who builds or improves thereon.and who doessuch work himself or through his
own employee,provided Out such improvements are not intended orofferedCorwin.If. 601 — ROOF TEAR OFF
however,the building or improvement is sold within one you of completion,the owner.
builder will have the home.of proving Net he did not Wild or improve for purpose of 602 - ROOF PLYWOOD NAIL
.a)e')' 603 - ROOF BATTENS
❑1.as owner of Me property,am.cl.ively contracting with licensed connectors to -
masticator Via project(See.7tea,Basin.and l,ofe.lons Code:)noContractors Li. 604 - ROOF IN-PROGRESS
came law does not apply to an owner of property who Wilde or improves Morena.and
who contracts for such projects with a conuector(q licensed pursuant to On Contractor.
License Law.
❑I un uempt under Sec. ,B,k P C for this match
Owner Date -
WORKER'S COMPENSATION DECLARATION
I hereby&Ron under penalty of perjury one of Me following exclantiom:
I haw and will maintain a CenlEwu of Commit to self-insure for Workers Cooper.
7371M
on,u provided for by Section 37W 0(the ISM,Cade,for Ne performance of the
k for which this permit is issued.
1 Mw and will.maintain Workers Compensation Insurance,u required by Section
of the Labor Code,for the performance of the wok for which this permit i.issued.
Worker.Campemlionln.unntt cenier and Policy numbs,art:2 / urier. Policy No.-S7 _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(T os section need not M completed If the permit is for one hundred dollars(Slag))
or Icsa)
I certify that in the performance of the work for which this permit a issued,l.hail not
employ any permn in any m urecrsn u in become subject to Ne Workeri Companation
Lowe of califomis.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cculdrleete of Exemption,you Mould
become subject to the Workers Compensation previsions of the Ichor Code,you must
Oforthwith comply with such provisions or this Permit shell he dcemcd revoked.
CONSTRUCTION LENDING AGENCY
I hereby allirm Nu fart is a convection lending agency for tM perfurmaa of
Y, the walk for which Int.permit Is issued(Sec.3097,Ci,C.)
0 Lender's Name
z Lenders Address
J Q 1 certify Net 1 have rood this application and sate that the above oformnion is
y H correct.I agree to comply with all city and county ordinances And sate Iowa relating to
0U building convection,and hereby authorize rep=nutiws of Nis city la enter upon the
Na aMvomentioneel property for inspection purposes.
(We)agree t.save,indemnify end keep harmless the City of Cupertino against
fn liabililies,Judgmcnu,cos.anal eapcnue which may in any way accno againslsald City
:,� In conaquence of lh ming of ll' pe f.
APPLICANT U STM L COMP WITH ALL NO POINT Issued by:9 *Date
' SOURCE R
3 Re-roofs
Sigrwum ofApplimnUContralor De¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theepC.,nitar future buildinglo.Chaptetom.heMlc Health material
As dcgned by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
ode.Section]553](x)? , All roofs shall be inspected prior to any roofing material being installed.
❑Yce
Will the applicant or future building accupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvamou. I,comamaenu a&road by ft Bay Asa.Air Quail,Management all new materials for inspection.
❑Yas gSrvu
I have mad the sardnus maariab izemenau Jer Chapar d.HS of the Califor'
hie Ncalthgtsefct c,Sr(:don 3 Sand 1% l andcyend thmiffw Wilding
aims not c o Na I i yl'y lge occupant of the /—✓ sL.-J
myviremcnu ,iter mu ole mEmal u c `
�" Signature of Applic nt Date
Owner Co authoriyeJ agent p,�' All roof coverings to be Class"B"or better
1 Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
qUPEkTINO
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:
Job Site Address: 1 0
Roofing Company Name:
A plicanYs Signature: LTJ -- �/�--= Date:
Greg eel
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
REROOF v
= CUPER INO PERMIT APPLICATION FORM
APN# / Z v 5 Date: 9 /2 3 /0-3
Building Address:
Owner's Name: C/L Phone#:
Contractor PhA e#: License#:
Fs q4
Contact: (� � Phone#: Cupertino Business License#:
'fLJ omens_
Type of Roof Covering:
Existing: Proposed:
�Q Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles * Asphalt Shingles
X 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, UnderstandW'll Com With Cu ertino's Tear Off Policy:
Job Description: T O an ^C D y
Residential Commercial rl
Fire ne: Yes Confirmed with P
-- there are antrictl s:
Cost ofProject: 11 Type of Construc o : Occupan oup:
qi3 . �
Qty-
A licf le Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
J BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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