04080238 CITY OF CUPERTINO �sMrr�. �F `" `'`�'"E""'
BUILDING DIVISION PERMIT C0 , &T.ORINF®RMA, A
BUILDING ADDRESS: PERMIT N0.
T D ROOFING 04080238
OWNER'S NAME: PERMIT ISSUE DATE
(2 )
ONE:' SAMTARY 2 OL NO.
(40A) P92.-RA79
ARCHITEM&GINEER' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
Lop
LICENSED CONTRACTOR'S DECLARATION Job Descriptionwth
u 1 hemby affirm Nat 1 am]icenud maker roviaimns of Chapter 9(commencing
W with See".pp 7")oI'D ivi"..3af Nc Busioind Profiessions Coda and my]teems is
amn@gtand ft `e 6 !o � REROOF W�SHAKE
,'�= Lipen l L�.• SEP �' 2004
Fp Da¢ Can
ARCH CTS 0 RATION
s-i I undersand my plans
.hall be used az public rttnrda
O y Vy®®`��
3 0In Licensed Pmfessi...I U I L®1 9 YI
3 OWNER-BUILDER DECLARATION Contractor'.
ON
+� 1 grosso affirm faro 11. cacmpt from Ne Convenor's Code:Any c Law for the
'•p o following mown. onion t )comm Business and Pono,o.d sioas h.orAny city s county
S:0
which require a permit m rnnmmet,alter improve.Jemnlicb,or repair any swaum
Fiy prior to its issuance.also or,imes the applicant for such Permit to Olc a signed statement
< ma Mislicerucdpursuant toshe provisions Ofthe COmmann'sLicense: aw(Chapter 9 Sq.F[. Floor Area Valu tion
rc�" feommencing with Section 10000 of Division 3 of the Business and Professions Codc)or
y $ that he as exempt therefrom and she basis for also alleged exemption.Any violation o1
Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of 3%,PN4,ber00 Occupancy Type
not mort Nan himhundred dollars(5500).
0 I,a owner of the pmpcay,or my employee with wages as their sole compensation,
will do the work.and lie sumnum is not intended or offered for sale(Sec.1049,Business
and Profassions Code:The Ccmmetars License Law dors.1 apply Ire an owner of
Required Inspections
property who buildsor improves onemon,and whodoes such work himulrar thmugb his
own employees,provided Nat such improvements am not intended oroRered forsale.If.
however.the building w improvement is sold within mm year of completion.one owner
builder will have the Written of proving that he did that build or improve for puryasc of
sale.).
0 1,as owner of the property am reclusively commeting with licenacd romacmfa to
consumer the project(Sec.1044,Business and Professions Code:)The Coh=mr's Li"
Genu taw dors not aPPly to an owner of property who Wilds or improve thereon.and
who contracts for such projects with a conva<mr(x)licensed pursuant m da Connector's
Lkcnce caw.
❑ I em exempt antler Sea .8&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby rRrm under penalty of perjury one of be following bxhostions:
I have and will mainuin a Certificate of Conant to elf-moms for Worker"Compen-
asumm,as provided fm by Section 3100 of Jm LOW,Code,for the perf i man.of the
ork for which this
permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
7 0 of Bic labor Code,far the performance of the work for which this perma is issued.
My Warkefs C,yy�mpe-n}sation lnscanicr and Policy number are, ^7
Cartier. � IC\\a --j'1tlA��oliq No.:
CERTIFlCATE FE% ON FROM WORKERS' _
COMPENSATION INSURANCE
(Thu¢coma need not beeompined if the permit is formic hundred dollars(Slip)
Or less.)
I certify that in the performance of the work for which this permit is issued,I shat]not
employ any person in any manner was to become subject to the Workers Compensation
Law.mf C.Iifomia.Doc
Applic nt
NOTICE TO APPLICANT:If,after making this Ccnificam of EacmPtion•you should
become subject to the Worker.Compensation provisions of the labor Code,you must
.JO forthwith comply with such provisions or s Permitsbe hall rimmed revoked.
z .~N.. CONSTRUCTION LENDING AGENCY /
[-. I hemby aRrm Net oncrt is a consumninn lending agcnq In,Nc perfurmance of
6i 7 Ne work for which this permit is issued(Sec.3091,Cie Q
W Q Lcndcr's Namc
6, loader's Address
f J I certify Net I have read this ap,licrom.and sum fast the above information is
W F contact.I agree m comply with all city and county Ordinances and state laws mlating to
0U Wilding construction,and hereby.uthrriu repraenuties of this city in cater upon the
r W above mentioned pre eny far inspection puryoui ...eee
D. (We)agree to mine,indemnity and keep hnmlw Ne City of Cupertino against '
F" h liabilities,judgments,costs and eaperum which may in any way accrue agamstsaid City
U z in APPL CANTcUf faEgranting
Ahis Perrot.L
NDStAND WILL COMP�TH A L NON-POINT Issued by: Date
SOURCE REGU A 0 5. 1/
a 1 G /
o W Re-roofs
6 Signaturcof ApplicaMConormn, Win
HAZARDOUS MA IS DISCLOSURE Type of Roof
WBthcapplicamorfutum Wildin m ant stem of handle hccuses numial
u defined by the Cupertino Mu em.)C par 9.12.and dm Healon and Safety
CWe.Sccvon 25532(.)? \/J All roofs shall be inspected prior to any roofing material being installed.
El Y. ®Nm
Will the applicant or f'ut`ure building occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air conmmiments as dcOned by the Bay Area Air Quality Management all new materials for inspection.
Distrin?
Oyes AN.
Lhave icedthe hvardoemannish 5533 itc 5514.1 rChapmr6.95 if one Calif.,
his Halon&SafnyCodc,Sec an 25503.25513 and2553d.lunderstmq thuifJe Willing
does amt mmnamty haM n n that it u my responsibility m notilY the occupant of Je
mimmmnn which sort a tpoor mUse ren eeni0eam mf6 . 6X 0 Signature of Applicant Date
Owner OFalltho 6, 'g t Date All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
, Telephone(408)777-3228
CITY OF Fax(408)777-3333
'jVUPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
11 100 `�okoreS -1VQ v � :
OWNER'S NAME: K Cam% PHONE # y S aSS
GENERAL CONTRACTOR i D iZoQV:V\q FAX #
I am not using any subcontract o 8 A 6 0
Signature Date
Please check applicable subcontractors and complete the o owin 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
—17 Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signa Date
Community Development Department
Building Division
City of Cupertino
CC
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPEkTINO
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 LC.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: 1t arp% A <.z,0 UR m o. to
Job Site Address: —a I cl 00 J/oL T e S -A< C,
Roofing Company Name: I D oo t IAC)
A plicant's Signature: � Date:
eel
Greg t
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO � o 2-3
Id REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 S 1 A. Date: S 2 6 ( o y
Building Address:
,� IGI 'Da —Doi otieS AJe
Owner's Name: Phone#s
I{ c.m' ct So�e . ral�v\� ..108)
Contractor: Phone#: License#:
T D JZoo � . .10X ) .14`1 I Oyi
Cent t: Phone #: Cupertino Business License#:
I�cx�i c� cS 6 46 $ 3 So
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
91 Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) A Other(Specify) M ova%eV -
Number of existing coverings ❑ Provide I.C.B.O. Report# A GS 6
To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: ff� (�
remove Wood SV1ctQ�e. 7Le IaC.I VQ a a� �e SNCL
Residential Commercial ❑ COV) arc l
Fire Zone: Yes ❑ No ® Confirmed with Planni if
there are anre ' tions:
Cost of Project: Type of Coonnstrucctioor Occupancy ou
p r
Qty
Ap is le 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