04080204 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC!TI`OR4NF,ORMATION :'.
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BuaolNc noDRtss: MONKS ROOFING +- PERMITN 040802 OyI
OWNER'S NAME: FERMITISSUEDATE
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ONE: SANITARY O. OL NO.
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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=00 LICENSEDCONRACTOR'SDECLARATION JobDescri tlOn
w.C I hemby affirm that 1 am Iicenacd under provisions Of Chapter 9(ommcncing p
nF a9 with Scetion]IXXB o- Busincv aM PmICSs_iytyC Yliccme ix
s in 0B forte and /) 7
oq? Liner. ue.g REROOF W/ COMP.
Dam can DEC
QQ A n'E
HCS DEC N
a-s 1 understand my phos shall w uxd ss'optic records 2
�yU
;0� Licensed Pnrfcssional
5 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Committees License Law for the u
n O following mmrn.(Section 7031.5,Business and professions Cole:Any city or county
which.quires a permit in crown,arm,improve.demolish,or.pair any xtrucmre
Fly prior m its issuance.also requirms the applicant for such Permit Rlc a signed customer,
< Na he islicerscdpmsuanttothe Provisions ofthe CommsuisliaxnxLaw(charter 9 Sq.Ft. Floor Area Valuat on
,FG (commencing with Section 7BOB)of Division 3 of thc Businessand Professions Couc)or
y that he is...of 0icmfrom and the bash for the alleged exemption.Any violation of rn.o7.i�,,ys,.,.,a,
Section 7031.5 by any applicant for a permit subjects one applicant to a civil penalty of 3-9 Nfta grOO Occupancy Type
not mo.Nan five hundred dollars($500).
❑1,as owner of tM property,or my employees with wages as their sale compensation,
will do the work and the structure is not intended or offered for ale(Sec.7061,Business
and Professien Cada:The Canmcmes License law does not apply to an owner of Required Inspections
property who builds or improves thereon.and who does such work himself or through his
awn employees,provided that such improvements are not intended oro@red for sale.If,
however.the building or impmvcmcn,is sold within one your of completion.the owncr-
wildcr ,will he.Ne burden of proving that to did not Wild or improve for purpose of
sale.).
1,as owner of the property.am exclusively contracting with liecnsed contractors to
construct the project(Sec.7014.Business and Professions Code:)The Contractor's Li
cense Law docs not apply in an owner of property who builds or improves thereon,and
who contracts for such projects with a cmaractor(s)licensed pursuant in Iw Contractor', .
License4ff E] Law.
1 am sacro',undo Sec. .B&P C for Nis retia
Owner y �� Da. �\
WORKER'S COMPENSATION DECLARATION
1 hereby effort under penalty of perjury one of O.following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compcm
senium.as provided for by Section 3700 of Ne Labor Code,for the performance or the
work for which this perms,is sound.
have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for d.performance of she work for which this permit is issued.
My
We fompensation Inman carrier and Polity n/umbeers q��
Cagier N t policy No.:/)-�V
CERTIFlCATE OF EJ EMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not w compiemd finite permit is return hundred dollars(SIM)
or Ictus)
I certify that in Ne performance of the work for which this permit is issued.I shell not
employ any pmaon in any manner an as in become subject in the Workers Compensation
Laws of Caliromia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject be the Worker's Compensation provism.of the Laver Code.you tru
.J Q forthwith comply with such provision or this permit shall be deemed mvoked.
Z'" CONSIAUCf10N LENDING AGENCY
'rt rA I hereby affirm thatthereis a construction lending agency for the performance of
!Yi 7 to work fur which this permit is issued(Sec.3097.Civ.C.)
toe] L cmler's Name
Lenders Add.
7
IL O 1 certify that 1 have rad this application and sum that she short Information refning h
Ire. E' bonding l agree to comply with all city and county roadws Of and sus enter
sating,o
0 ahovcrgcotionedon.and hereby authori.mpresenulivesafthisCity,o enter upon the
Y' ahovc(We)are property for inspection keep ha
F a
(We)agree,o sa..imemnifm and keep hymn9dookens Wayhe se or caainst id Cit,
rq liabiliues.judg n.costs and a'enes which may in any way accrue against mid City r�-79(� z in eonseque o Nd granting of Nis permit.
'-' APPLICA y DERS A DS AND L COMPLY STN-1 ALL NON-POINT Issued by: Date
SOURC ULATION •' r/
CJ V Re-roofs
Signor of Applicro UCOMMerer Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will one applicant or future building Occupant store or handle hvudous material
as defined by the Cupertino Muni trip otic.Chapter 9.12,and the Health and Safety
code,stiction 25532(1)1 All roofs shall be inspected prior to an roofing material beim
❑Yes p P Y g being installed.
Will the applicant or future wilding occupant on cquipmat or devices which If a roof is installed without first obtaining an inspection,I agree to remove
in havardnus air comamin ms u Jcfymd by Ne Bay Ama Air Quality Management all new erials for inspection.
7d.
strict?
❑Ycs
I have real the hmaNnusmamrials requimmcnts under Chaps 6.95 oftle CalifonJ-
Halth& army Cade.Secden 25505.254)3 am125534.I ralcosami mifthe wining
not c nthy he. .nam.union ex myl(sporribility m notify the occupant of the �C
imm (wnitting emy/yF}yn p faccoiratoaroeap� LgnatoreofApplicant ate
ner or uthonzcd agent ' e All roof coverings to be Class "B" r better
Community Development
10300 Torre Avenue
l-�L_ / Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
Svc ; N W . 0'-f0T0
OWNER'S NAME: Sbk J c>c PHONE #
GENERAL CONTRACTOR: yv- \)rJ )CS ",( 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
Septic Tank
Sheet Metal
Sheet Rock
ile
Owner/Contractor ignature Date
Community Development Department
} Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
' PEkTINO 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 Lwith the above stated policy on re-roofing.
Homeowner's Name: Sar
Job Site Address:
Roofing Company Name: c S r(IU0 b l
A plicant's Signature: Date: !/ �7 0
® Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOFCITY OF
CUPERTINO PERMIT APPLICATION FORM
APN #� Date
55 2 � o 1 I
Building Addr VSs: J
J
Owner's Name: Phone #:
ohlV v_uvU tri a2 D
ContractL Phone#: _(7 n License#: C 602
o
7
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles �® Asphalt Shingles
Wood Shakes ❑ Wood Shakes
Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings -2— ❑ 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 Descri tion:
b4c gxS 1
Residential Comm rcial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anrestrictions: LJ
Cost of Proje r Type of Construction: Occupancy group:
O�
Q . if
A 1' t ble Fee ID Fee Description Fee Group
LV 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
� 6 �