04100073 CITY OF CUPEMINo
nmf.owc mvlsloN PERMIT CONTRACTOR INFORMATION "-a
n5.. d.Lu✓ ,r. .k P.
BUILDING ADDRESS: PERMIT M18.4
1324 DEXTER DR
OWNER'S NAME: PERMIT L6UE DATE
MCCULLOCH 1771 SMITH AVE . 10/12/2004
]ONE: SANITARY NO. CONTROL NO.
(408) 298-9399
ARCHI7LCTIENGINEER' BUILDING PERMIT INFO
¢ BLDG ELECT PLUMB MRCH
LICENSED CONTRACTOR'S DECLARATION [� � ® O O
i�F 1 bunchy affirm that 1 am licensed under provisions of Chapter 9(commencing IYpI q�,BgU 1 tl
with Section 7008)ler Division3ufne Business and Professions Cndc.an myli.enm is
mu n,nte and er t REROOF W/SHINGLES
p�? Llcento s ` Lic.x
neo Da 1 - G.ntmetpn /
ARCHITRCPS DECLARATION
K a 1 underxWnJ my Phnx shall b.used as public mits NOV 1004
°iU
3 Licensed Professional
�U I�®� R
OWNER-BUILDER DECLARATION
F 1 hereby xlfrm thm 1 am exempt Item the Contractor's License law lits the
00 following roma.(Scctiun 71131,5,Business and Professions Code:Any city nr county
im u which requires a permit nr au soon,sl cr improve.demolish,or repair any structure $7432
'apriorto its issuanec,also requims be applicant for such Permit
m flu asigntJ statement
< that he i.licensed pursuant tothe pmvismnsofthe Contractor's Locust,Law(Chapter 9 Sq. Ft. Floor Area Valuation
asi-° c
(comm s00x
(commencing with Section 7000)of Division J. ess f the B usinand Professions COde)ur
i 5 Nat he is exempt therefrom and the basis fur N.alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects he applicant to a civil penalty of be Occupancy
a.,more can five hundred dmlars($500). P Y Type
E]1.as owner of the pmpeny,or my employees with wages m their sale compensation,
will do the work,and the wrichere is nut imcndcd m offend for sale(Sec.7044,Business
and Professions Cade:The C.mhaclurs Li,cm.Law does at apply to an owner of Required Inspections
property who builds or improves Neuron.and who does such work himttuor through his
tun employees.provided that such improvements are not intended or offered for sale.If.
however,but building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving Nat he did not build or improve fur purpose of
salt.).
C)1.as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7w4,Business and Professions Code:)The Contractors Li.
ease Law Nee nal apply at an On.,of pmpeny who build.,or improves them..,and.
who contracts for such projects with a eomracum(s)licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason
13n700
wner Date
WORKER'S COMPENSATION DECLARATION
1 hereby M.under peter ty of perjury arc of the following declarations:
1 have and will maintain a Ccrtifeam of Consent to self-insure for Worker
N 's Compen-
tion,as provided for by Section 37M of the labor Code,for e performance Of the
rk for which has permit is issued.
1 have and will maintain Worker's Compensation Insurance,as acquired by Scctiun
of the labor Codc.for thissc performance of the work for which this permit is ncd.
yWarkcr'sC pensminlnmmnc,caoicradpolicy.amhxrntact: ( OND PolicyNo.:�.a7 ;20
CERTIFICATE OF EK EM MON MOM WORKERS'
COMPENSATION INSURANCE
(This semion need not be completed if the permit is for one hundred dollars o III))
or Ices.)
1 certifv Nat in the perroarm res Of the work or which this permit is issued.I shall not
employ any perenn in any manner so as m become subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifcas of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code.you must
7 forthwith comply win such provisions on this pumll shall b.deemed revoked.
Z O CONSPRUCTION LENDING AGENCY
`+ I hereby affirm chat there is a construction lending agency l or the Performance of
C? Or work fur which bis oemait is island(SO,.3(N7,Civ.C.)
W Q Under's Nam.
LcndctAddress
O Q 1 cenify that 1 have read Nis application and sure that the above infranialun is
W F cocorrect,,Iagree Ic comply with hereby city and county mJun,s of and cute laws relating e
buildingcon,,ncd roertt fany awbon prposes lativcs of this city to cntcf upon the
CL abnv,mentioned Property for inspection purposes.
(We,agree to cast,indemnify and keep harmless the City o Cupertino against
Ute, incrbi ruirt nce Of tal.the costs and ox penxsanit. may in any wayaccrue against said City ppp y
CJz Aconsequence of DERSTAN.f this permit. /1 /
APPLICANT UNDERSTANDS DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date C/
SOURCE UL IONS. _
f�
Re-roofs
a.rp AbpS anveontqfa,tor Date
�TAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant star,or handle hmarduus motorial
as defined by the Cupertino Municipal Cate,Chapter 9.11,and the Health and Safety
,idftcodr. zss_3al7
Ox Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment os devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit haaardnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
istricl7
]Ycs �uu
Ihavc read the ha"sad as materials mquimmentsundtr Crate,l.9Sof the Califm.
ria Hcalth&Safety COs,Sccdorts'SNls.25533 vu1155Jd.1 unJcrsmnd thairJc building
dons not currently ham a tenant,Oat it u my responsibility m ma r y the occupant Of the ./ V
requircm¢I�.Cw ch stMmcl pnnnn issumcc nfa Ccnifca¢O��upancy
4 Sig atuplicant Date
Owner orinthm;.d ,at DSIO All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
> Cupertino CA 95014
(FpeEY Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER' e LLD PHONE # oe .2 - j3 Q
GENERA CONTRACTOR: FAX # vd� 2
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 p1 l� / ,�jN 2 yd'/
Septic Tank
Sheet Metal
Sheet Rock
Tile
r/ ontr ctor Signature Date
Community Development Department
Building Division
(' . l City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
CITY OF Fax: (408) 777-3333
SCUPEkTINO
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 coImOly /with the above stated policy on re-roofing.
Homeowner's Name: LOA Reil aOoU //OC h
_ Job Site Address: __ c132_q__ .__T)eAer_ _.Uf_'
. _ .__._.._._
/
Roofing Company Name: L6S V 4_-A) Is
Alicants Signature:::p gn Date: 0 !l
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN # 321z2-q1- Date: G/
Building Address: ,2 )32L/ l\e d -e r Dr . y
Owner's Name: ylc nk mo& /� Phon #: 2-
Contractor:Contractor: Phone#: License#:
os Gwf�S R yap , - (W707
Contact:_ Phone#: Cupertino Business License #:
l/2CcNd -c73q9 23Y91
Type of Ifoof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles /� p ❑ Wood Shingles n O S�/ /�
Other(Specify) I .e/Y/LJnnGf ❑ Other(Specify) 4C/J t�/S Sp le,7
Nymber of existing coverings ) ❑ Provide I.C.B.O.Report#
`C To be Removed ❑ Provide Mfgr.Installation Specs. '
I Have Read, Understand and Will Com 1 With Cu ertino's Tear Off Polic
Job Description:
ou�J ��ib OS6 4 TL .
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Det. if
there are any restrictions. LJ
Cost of Prcjec�: h Type of Construction: Occupancy group:
/43 2. O d �C E P,Od rz GLE JL
tq. if
Applfcable 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
z 73 f d'
Z��(�Y. 76