03090016 rCITYOFCUPERTINO
BUILDING DIVISION PERMIT6RMA
*.�4,CONTRACTOR TNFTTON
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BUILDINGADDREss: TEO ' S ROOFING PERM;TN003090016
29 I2RR2T1_1NR DR
'ER'SNAME: 691 W SAN CARLOS PERMIT ISSUE DATA
NE: (408) 279-8797 SANRABY NO. COMROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION JOh Description
0u I hereby affirm that 1 am liam
med under provisions of Chapter 9(commencing Job
4� with Section 7")of Division 3 of the Businnsend Profession,Codwand my license is
in full farce end CCL p��
,gz Lmmse Ina �- Lie.« REROOF FINAL1530
c
,PM Doc Cumrecm _
illW ARCHITECTS DECLAR a eg «J
Iunderstandmyplan,shallbeusedupublicretards SEP 9.2UO3
y'tt; Licensed Professional
iS OWNER-BUILDER DECLARATION
<l I hereby mlTum that I am exempt from the Contractor's License Lew for the
C O following measure.section 7031.5.Business and Proresduh Code:Any city or musty BUILDING
$ which require a permit to construct.alter,improve,demolish,or repair any urucmte
print to its issuance,also requims the applicant for such permit to file a signed statement ..
EEx that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7(00)of Division 3 of the Business and Professions Code)or
Net he is exempt themef errs and the buil for the alleged exemption.Any violation of 36224039 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN.Number Occupancy Type
not more than five hundred do1Hu($500). - ---- ----- - -
I,as owner of the property,or my employee with wage u their Sale compensation,
will do the wok,and Ihmwaure is oat intended or offered for Nc(Sec.7044,Business
and Pmfessioh Code:The Contractor'.LiaSve Law does not apply to an owner of T uired Inspections
property who Wilds or improves themon,and who dmssuch work himulfor through his 307 - INSULATION
own employees,provided that such improvements are not intended oroQered for Sale.If. 601 - ROOF TEAR OFF
however,the building or improvement Is Said within one year of completion,the ownco-
builder will ban She burden of proving Nat he did not Wild or improve fm purpose of 602 - ROOF PLYWOOD NAIL
ea 1. 603 - ROOF BATTENS
❑1,a t the project of Ne(Sec.7W.
.B siness velyand confessions Co1;iceneed convectors t.
come La doespplytooaowerof and professions bd&or i tneversdamta Ll. 604 — ROOF IN-PROGRESS
whose law dos not apply loan owner of psopeny who licensed
or improves Cocoon,and
who.Lace for each projects with a conuumr(p Iicense0 pursuant m the Convector's
Lim.
❑Ism exempt under So. ,BkPC for lhi>muon
/ r Dau
( WORKER'S COM PENTMONDECLARATION _ ..
I hereby,affirm under penalty of perjury one of the following dolarations:
I hew end will maintain a Certo(mof Consent to self-inure far Wokeri Compere
cation,as provided for by Section 37M of She labor Code,for Ne performance of the
work for which this permit is issued.
I haw and will maintain Workers Compeuadon Ihurace,as natural!by Section
3700 of the Labor Codefar the performance of the work far which this pCmlit is issued.
My Workers'S7-)Q
Compensatioon-Insurance artier and Policy num her am:
Cartier. J 7� ` 11` Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This satire need..hemmpleted Kthe permit u fmmn hundred dollars(Slip)
or Ice.)
1 arify Na in the performance of the work for which this permit is issued,1 shall net
employ any person in any member an u to become subject o the WOtk U Compehpion
Laws of Celifomla,Data
Applicant
NOTICE 7O APPLICANT:If,after making this Certificate of Exemption,you should
comma subject in the Workers Compensation provision of the labor Code,you m se
�p forthwith comply with such provisions or this permit shall be deemed revoked.
z ry. CONSTRUCTION LENDING AGENCY
I hereby affirm Nat thea is construction[ending agency far the perfurmsme of
Yi the work fur which this permit is issued(Sec.3097,Civ.C.)
4Lenders Name
1. z Lenders Address
J Q I cenify,that 1 haw read this application and sate Net the above information is
J.F correct.I agtee to comply with all city and county ordinances and note laws misting so
'U building connection.and hereby authorise representatives of this city to enter upon the
ah n-bonotianed properly for inspection purpose,.
ti (We)agree to saw,indemnify and keep harm;oss dm City of Cupertino egeiht
h liabilitiu,Judgmcnu,cord and expchcs which regi,any way ucruc again;trod City
JZ, in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
R EDUCATIONS.
Re-roofs
S' of Appi nUConvacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or future building uccupanutere or handle bvardau,material
u def need by the Cupertino Municipal,Cade,Chapter 9.13,and the Health and Safety
.
Section 35s3:(a)7 _/ All roofs shall be inspected prior to any roofing material being installed.
Y. Y"
Will the applicant or future building occupant use equipment or devices which If a roof Is installed without first obtaining an inspection,I agree to remove
it harudrus air contaminants u nd by the Bey Arta Air Quality Management all new materials for inspection.
isuict7
❑Yes a
Iban mad the haa4rcrosmateriaHm33 and 5534.1rChapeer rstand at ifthe Wilding � /�
.is Hcolth&Safety Code,moven,Oat
35534.1 obadand Natifthe ,or the
dao ort cunen0y Aave a tenmk that it is my responsibility Ir notify the occupant of the
myyispfynu h' once etpriorloi uanc of.cem!" ato2rom"Pubcr ri of Applicant Date
Owner raushodvMegc �_JJDate J All roof coverings to be Class "B" or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
UPERTINO 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: 1_" �Almcsgq
Job Site Address: \\Q,( o C:C�
Roofing Company Name:
A plicant's Signature: Date:
61 U
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
' CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# Date
ZS C� 3 v
Building Address:
CD
Owne 's Name: Phone#:
A $5 Q
Contractor: Phone#: License#:
1111 \
Contact: Phone#: Cupertino Business License#:
Sac'O. Ocexc� 7a
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
A Asphalt Shingles A Asphalt Shingles 4W ke-r
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) — 13 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:
Ve CR fiDn
Residential Commercial ❑
Fire Zone: Yes ❑ N Confirmed wiOrtlanning De t. if
there are restrictions: LJ
Cost of Project, Type of Co M.
Occupan
Qty. if
Applicable 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