04030179 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ¢,t,PNTRACTORINFORMAWON:
BUILDING ADDRESS: PERMIT N0.
T D ROOFING 04030179 '
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECt PLUMB MECH
1� 0 � 0
L Op LICENSED CONTRACTOR'S DECLARATION lob Description
w❑ 1 hereby affirm that I am licenced under pron visioof Chapter 9(commencing
=N Fw with Sectun7")of Division 3 ofthe Business and Pmleesioas Code,and my license is
in full foreeand effrt.,y Ci LeN 66 aa- REROOF IW�ulrr rp�gggll(��y},�pp {y®.
Oviz Licence Cl s .Jf�Cunlrazlor OQ r+ �" `"a�a'stmro
ARCHITECTS DECLARATION
I understand my plans shall be used u puhlie records MAR 3 0 2004
wMo Licensed Professional
S OWNER-BUILDER DECLARATION ®� pp�pw�,
P 1 hereby affirm that I am exempt ffum
the Contractors License Law for the V ISL®�Y\V1
p O following moon.(Section 7031.5.Business and Professors,Cade:Any city at county
x m which requires a pewit to construct,alter,improve,demolish,or repair any structure
w�'^ prior to its issuance.also squires the applicant for such permit to file a signed statement
5Ea that he isliocnsedpursuantmtheprevisionsofBic ContracmriLt..law(Chapter 9 Sq.Ft. Floor Area Valu tion
,Fe (commencing with Section]BOB)of Division 3 of the Business and Professions Code)or
ave•R R that W is exempt chemfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3 M_1 er0 0 Occupancy Type
not ream Wan five hundred dollars(SSW).
I,ns owner of We property ar my employees with wage az Weir cele compensation,
will do the work and the sweturt is not intended ra.Mrasl forsale(Sec 1814.Business
and Profession Code:The Canuacwes License Law docs oat apply to an owner of Required Inspections
property who builds or improves Orison,and whodoessuch work himself orNmugh his
own employees,provided that such improvements one not intended oroffem l for cele.If,
however,the building or improvement is said within one year of completion.We owner-
Wilder will have Ue burden of proving that he did not Wild Or improve for purpose of
sale.).
F9 h as Owner of the property,am exclusively contracting with licenced contractors to
construct the project(Ste.7W,Business and Professions Code:)The Con rachm's U.
ceme law does not apply to an owner of property who builds Or improves themon,and.
who contracts for such pmjecu with a conuactor(s)licensed pursuant to the Contractors
License Law.
I can exempt under Sec. ,B&P C for this mason
owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty,of perjury one of the following dcclanlions:
I have and will mainuin a Certificate of Consent to self-insure for Worker's Compen-
ion,n provided for by Section 3100 of the labor Code,for the performance of the
w
ork Lak for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,u required by Section
of the bor Code,far We performance of We work for which thisperi,is issued.
y Workers Coompennsation Insurance canier and Policy number are:ncer. 51 Q LQ. -r 3.lV�P Polity No.: 14 a t S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseclion reed not W complewd if the permit is[crone hundred dollars SIOI)
or ca.)
I certify dust in the Pcdmmenee of We work for which this peered 6 issued,I shall ml
employ any person in any manner so as to become subject to tW Workers'Comfxmaauon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Campcnsmion provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall W deemed invoked.
'Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem is a construction lending agency for the performance of
X 7 We work for which this permit is issued(Sec.3091,Civ.C.)
Wp Lender's Name
W
a Z lender's Address
U C) I certify that I have sad this application and sum that We above information is
ly F COOCCL I agree to comply with all City and county Ordinances and sum laws relating w
p V building convection,and hereby authome mpremmativcs of chis city w enter upon We
04 (We)agree to save,indemnify and keep harmiless;
an Be City
niCupcnitaagainst / C
Uh in consequence
of the
mstsang expenses which may in any way ecemc against aid City
U z A APPLICANT
of UNDERSTANDS
granting Of this permit. C//`-y�
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE�`'yyAAP�ONS. I
d 01 76A�� J 101 o Re-roofs
Signature of AppbcanbCantrzcmr Date
HAZARDOUS RIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant swm or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.
smtim zss3z(an Yes All roofs shall be inspected prior to any roofing material being'installed.
Will the applicant or fw Nu re building Occupant Use equipmentor devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hconcomitantsrdous air concomitants ve defined by the Bay Area Air Quality Management all new materials for inspection.
Disaic,l
❑Yes Nu
I have mad the hvaNnus materials mquiremen¢under Chapter 6.95 of the Califon
niaHeal th&Safety Cod,Secdms25505,25533 and 25534.1 undcrsund chat if We building 3I
does not currently has,a mane,that it 12 my responihihty w way de�eupant of dic l
quimmcnks hi unbcmespriorwissumccofaCcnficam f0c ancy. Signature of Applicant Date
30
authodaaa ascot Dam All roof coverings to be Class "B"or better
PTY
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
INUPEI�TINO
Building De artment
JOB ADDRESJ✓S: . 3E MIT #
Io 433 )ehiSov� AVQ. 04. o
OWNEWSN Stv\h Z o H PHO a.og) 2-55 -5r.92-
GENERAL
69zGENERAL 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 T l> Roo n a 3 155
Septic Tank
Sheet Metal
Sheet Rock
Tile
19 ' o `�
.6 /Contractor Sign lore —`� Date
i
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
*UPEkTINO 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.
atn
Homeowner's Name: .J eY)n zIt
� �
Job Site Address: 11 4 e YX Soh J e
Roofing Company Name: i D )too f, tt cl
A plicant's Signature: Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper '
CITY OF CUPERTINO
RERooF
v,? v � 7�
CUPEkTINO PERMIT APPLICATION FORM
APN # 6 _ ;z-9 0 ,4 -7 Date: 3 19 o �{
Building Address:
10433 DCvttSon -A
Owner's Name: Phoney S` - 3691
j f_ ` �f z In c\.v. 9
Contractor: Phone #: License#
l D moo F V\ to8 89 a. 88 -9. 6 6 G
Contact: 1 Phone#: Cupertino Business License#:
Le's �i oatn Ko8 89 -. 8 Vy-a-
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
A' Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) q Other(Specify) �wg�
Number of existing coverings ❑ Provide I.C.B.O. Report# .2r.S 6
ATo be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
np r_n . _ 3 L
JrI -
Residential EA �L Co cial F1l
Fire Zone: Yes ❑ No 14 Confirmed with Plann' De t. if
there are any restri ons:
Cost of Project: Type of Construct y�n: Occupancy grou
$ l0 01570he - daor
Qty. i
Appliq'able 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
Fe77