04100187 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COg L�tTRAC`TOR�INFORMATION
BUILDING ADDRESS: PERMIT NO.
ELLIOTT ROOFING 04100187
OWNER'S NAME: PERMITLSSUEDATE --- -
w
10NE:'. SANITARY OL NO..
'ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0, - LICENSED CONTRACTOR'S DECLARATION Job Description _
wF 1 hcmby affirm that 1 em limnsed under provision of Chapter 9(commencing - _ -
�i`uf with Secuon]0(g))rf0iviilonJofNc euNr¢v and Profession Code.mdmyliccncu -- - - -- - -
in full force arta etre ^LF eC-
>q_ -sen+t�wclass C Lr,a -1-3 REROOF W/COMP.
ZhZ Date Contractor
� RGCTS DECLO,1$I ION
1 un a sound alts u1Qt�meet&
;off Li JPm a I� - •- - - _
ER-BUILDER DECLARATION
I hereby affirm WNI em exempt f the Contractors
License Law for the
(allowing on.(Suction](31.5.Buie .ad sain.Code:Anycity0county
which myuiru a Permit to construct.alteq impmw.demnlih, ,
- - -- - - - -
Or repair any stnmurt
EZi priW mics lensed p,rBUntto to leeapplicant the Connector's
Law sUMmcnl
a rhotacism. withSection7 )ofDivionofortheBusines niccnshw(Cnaptcr9 Sq. FL Floor Area Valu wn _
w. (eat he is teem it dacreirous and of Division 3 But al eged Business and on.PreAny
Cuda)tie
i�� that he u exempt tMmfrom and the buts for dte alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant an a civil Penally of 3}VM40VO 0 Occupancy Type
not more Nan Eve hundred dollars($500).
❑1,az owner orthe pmpeny,or my employees with wages u Heir sole compenation,
willdo the work and theswcture is not intended oreffcred forsale(Sao 7014,Business
and Pmfeedom Code:The CorsLi
ones cense Law does not apply u in owner or Required Inspections
property who builder,improves tltereon,od whodoesaahwark himself.,though his
Own employees,provided that such imp ommcnu art not intended or offered forsate.If.
builder
Ne buil ding errimpmrcmensisano withinot year of completion,Ne ower of
builder will have the burden of proving Nat he did not build or improve for purpose of
salcJ.
I,as owner of the propartY am exclusively convecting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
come
Law docs 00upply m m owner of Pmpeny who builds or improm therton,and. —�-
whoeontnetsfOresucM1proA.with a eonuacar(s)licensed pursuant to Ne Contractor - "' - - --- - -
Liana Law. ��
Q l am exempt under See. .B h PC for Nis won
Owner Date
WORKER'S COMPENSATION DECLARATION /
1 hereby affirm under penalty of perjury one of the following declarations:
L I have and will maintain a Ccnificate of Consent to self-insure for Workces Compcn-
nation,az provided for by Section 3700 of the Labor Code,for the performance of that
work for which this permit is issued.
❑1 hale and will maintain Worker's Compensation luurance,az mquired by Secure
3700, the or Code.ror a perfarmmee of Ne work for whicM1 Nis permit is issued. ..
My'
0 pcm.a luuu9 carrier and Polity number sre: -
�- Carrier v Policy No.:07436 4 -
�4 :GATEOFEXEMPTION FROM INSURANCE
{�.
COMPENSATION OFEXEINS MOMW
V� ts�"nrcw not be completed lithe Permit is forone hundred dollars(SIM)
to less.)
I amity that in the perfam ecce of the work for which this Permit is issued,l shall not
emPl.y any pertan In any mannose az to become subject to the W.rkeR Compensation
Laws of California.Date
Applicant - _NOTICE TO APPLICANT:If,after making this Certif¢a¢of Exemption,you should
neeome subject to the Worker's Compensation provisions of the Labor Code.you must
.JO forthwith comply with such provisions or Nis Permit shall be deemed revokcd.
Z " CONSTRUCTION LENDING AGENCY
L.�. I hereby affirm than Nen,is a conatm d.lending,unt,for de performance of
rL Ne work for which this permit is issued(Sce.3097,CO.C.)
1 Q Lendc/s Name
= Z Under's Addw
V C I certify that 1 have mad this application and sure that the above infotmatiun is
V. F cordis.I agree to c cam ply with all city and county nNinmeda and slate laws miming to � -
V abovengc.ur.mirnana hereby euNorirertpsesenutiscs of this city to enure upon Ne -
t W ah.vc(W)afire pmpcny for inspection
mnify an purposes.
a
(We)agree to sarc,indemnify and keep nquobacred.
as the City na Cupenino against
UZ inconiu,juagmcn¢ and eapeuu whim may in any way attme againlsaid City
V z ACPLICAN eC th ening SNis permit.
APPLICANT STANDS A DWI MPLY WITH ALL N. -POINT Issued by: - DateP Z
SOUR E
.Re-roofs
tarepelican onDate
HAZARDOUS MATERIA.,DISCLOSURE Type of Roof
Will the applicant (court building occupant sure err handle alnmaterial
az defined by the CupertinoneMunicipal Cade.Chapter 9.12,and dim Health
N aand Safety
"djKlConc,16c10.25532(.)? r All roofs shall be inspected prior to any roofing material being installed.
Yes .
Will the appRcaat on future brining«drPant rex equipment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
emit har rdous air contaminants as refined by the Bay Area Air Quality Management all new materialsjor inspection.
District?
t]Yn
Iharc mad amd.ux ma"nalsreqummuma r Chapter6.95oftic Califrt,
no HwlN&Safes eek,Scc' 25505.25533and .IndstwMthas if the building
darn no Y nuc rte s is u rn mlblllly b Mdly 11K CCCrpNt.t NC
reyu' no which ptl.r afaceNfi.a¢or aP�n IgnatureofApplicant Date
ncir m arthnrim agent XbDate D All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
J Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #
o 1124)&&,05 46187
OWNER'S NAME: /77�2� p Q PH # — ZS
GENERAL CONTR, FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
O Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet ock
Tile
2r d�Y
er/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
SUPEkTINO 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.
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,
r ; 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:
Job Site Address:
Roofing Company Name: 9
A plicant's Signature: _ Date: G•5",
ee
.reg eel
Building Official
Revised 1/30/03
Printed.on Recycled Paper
10/27/2004 10 : 13 FAN 405 777 3333 CITY CUPERIiNO 2001/001
CITY OF CUPERTINO
REROOF
CUPEIZTINO PERMIT APPLICATION FORM
APN# Data: l�2 10
Building Address: C-+
Owner's Name: Phone#.
--MJLlo Du Ctiog��S3-3o92
Contractor: Phone#: License#:
I ' n (T-10AI
I3=t�7% X1439
Contac ino Bus ness License
t'64�-- -- CSI 0 L191--CCO 1 Phone#: Cupe}t259I�
Type of Roof Covering:
Fadsting: Proposed:
❑ Built-Up RoofC2Built-Up roof
❑ Asphalt Shingles *><Asphalt Shingles
�< wood Shakes ❑ wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) _ ❑ Other(Specify)
Number of existing coverings _ ❑ Provide I.C.B.O.Report#_
❑ To be Removed ❑ Provide Mfgr.Installation Spe•s.
1 have Read;Understated and Will Comply With Cupertino's Tear Off Policy: L-1—
Job Des cri tion:
?.� ons e,K8L._&-11FTL-11ctL� ux-Voo - r-er� ci:'kn. Co
Residential 'M Commercial
Fire Zone: Yes ❑ No 0 Confirmed with I lanning L7pt.if
there are any restictions: U
Copt of Project: Type of Construction: Occupancy grout;
Qty. if
Applicable Fee ID Fee Description _ Fee Group
j BPERMFEE _jLdZ Permit Fees BUILDING
B�ENERGY Ener _ BUILDING
�j BSEISMICRE Seismic Fee Res BUILDING
BSEISMICO_M_ Seismic Commercial BUILDING
— BPL.ANCHK Plan Check Fee _ BUILDING
BUSLIC Business License BUILDING