04070173 • CITY OF CUPERTINO
BUILDING DIVISION PERMIT SCO NTBAGT,OR INFORMATION
BUILDING ADDRESS: COSMOS ROOFING PERMIT N004070173
871 FERNGROEF DR
OWNER'S NAME: PERMIT MUEDATE
Ah DAVID SMITH
ONE: SANITARTNO. CONTROL NO.
(415) 493-6373
ARCHITECT/ENGINEER:
" BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ueat
0 LICENSED CONTRACTOR'S DECLARATION Job Description
z F I hemby affirm that 1 am littased under provisions Of Chapter 9(commencing Y�V
n� with Section?Ogl)of Division Sof the Business and Professions Code.and my license is n
_�N inmBrm«anderr�t L -7 �5tte� REROOF W/TAR & GRAVEL (�y�/\
D gI z License Class Lie.X Q1 71
SFO Date Cant r I . Atli; 18 20p
ARCHITECTS CLAR r
x -s 1 unticrarand my plain shall s //pR
DCV O
;0G Licensed Pmfcuional ®ZO
g OWNER-BUILDER DECLARATION
Conf ON r�gg
I hereby affirm Nat 1 am exempt from rue Cssions Co License Law for the I•C
0O rallowing reason.(Section
'7031.5.Business and Professions Calc:Any city m[aunty
K m which requires a Permit to construct.aIlet,improve,demolish.or repair any nmehoo -
'te"^ prior m its issuance.also rectins the applicam for such permito flit a signed statement
that he is licensed pursuant o the provisions of the Comoseor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5bya"applicant fon permit subjects Nit applicant to a civil penalty of 3—A9?N14ffi"er00 Occupancy Type
not more dean five hundred detan(SSBI)).
0 I.u awnu of the pmpeny,or my employrra with wgu u theb um compenWLiOn,
will do the worksod the strums,is not intended croRered forsale(See.7 W.Business
and Profusions Coda:The Contractor's License Law does not apply to an owner of Required Inspections
propeny who builds or improves thereon,andwho doessuch wart himselfar though his
crumemploycos,provided that such imfornments are not intended craRered far sale.If.
however the building er improvement is sold within one year of mmpleuon.Ne owuer-
builder will hoe the burden of proving that he did not build or improve for purpose of
tile.).
I,as owner of the property,am exclusively contracting with licensed eantnemrs to
couuuct the project(Sec.?Bad,Business and Professions Code:)The Conbuctor's Li.
cert,Law dins not apply to an owner of propeny who builds or improv Merton,and.
who contracts for such projects with a conlmcmr(s)licensed purseant to the Canuacmr's
Licca¢Law.
❑1 am exempt under Sec. .B k P C for this reawn
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of lue following declarations:
I have and will maintain a Cenifinle of Corsem a self-minute for Wortrr'sCompcn-
ution,u provided for by Section 3900 of Ne Labor Code.for Ne pe formance of dte
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by section
'AID of the Labor Code,for Inc pctfarmance of the work for which this permit is issued.
My Workers Cnm—Pe/saloAn Insanncoca sier and Policy number arc:
Cartier. S• 5: /r Policy No.; S-7/—O q—/I Z,_S ,
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcomplced Blue Permit is for one hundred dollars(SIM)
or Itss.)
1 certify Not in the scofoo anee of Ih[work for which this Permit B issued.I shall not
employ any person in any manner at as no become subjecua the Workers'Compensation
Laws of Califoria Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such Provisions or this permit shell M deemed revoked.
Z2 CONSTRUCTION LENDING AGENCY
F-' IMmby affinn Nat then iso cortructinn lendingagency'for dm Perfurmamre or
C 7 the work for which to permit is issued(Sec.3(141.Co.C.)
LendeNamc
G Lender's Address _
U Q 1 certify that I have mad this application and sale neat the above information is
D. F" coacca 1 agree to comply with all city and county ordinances and sum laws elating to
V buildingeonswctian,and hereby amhorie mpremnutivaf this city Mercer upon the
r fbl above-menumrad property for inspeetian purposes.
(Wit)agree to save,indemnify and keep harmless dle City of Cupertino against
D.y liabilidu,judgmcros.cosa endo s which may in any� pens[ w IWay aCCNe against Mid G'lly
U in consrqucncc car the graining of this limit. t
APPLICANT DERST D WILL' 1PLY`kvlT ALI�NON-PO Issued by: Date
SOURCE LAT 7 27 U
Re-roofs
Signature of Appliun✓Conaeemr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant store or handle haMmous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
alit.Section 25512(a)? All roofs shall be inspected prior to an roofing material being Installed.
❑r gaw— P P Y g P,
Will rue applicant or future building occupant use equipman(or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haMmous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes UNu
Ihavemvlthehv msmawrialsmquimmenuunik:r Chapter6.95of Ne Califor
ria Hrslth&SaretyCeal Srcuom 25505M533 MaUZ553C.l uncersand equ if the building (a'
docs rmt curmntl haat a umxm Nati y ruporihility m notify Nit amrymt of the
mquiremcnu bMostbe t aeaan[e c[ruryamorOc[ap ay. Signa[ureofApplican Date
ownerr r%mh� �. 1 ��a�.. All roof coverings to be Class nB„or better
Jul 27 04 07: 39a Cosmos Roofing (650) 969-9905 p. l
07/26/2004 13:35 51053R3282 LEG4LITIES Ihl: PAGE 01
�ldw�o
VAN. 194 4 40--P l-6-A-r L.'roJ338'-32.$'i
i Community Developmmr
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
i ..
Pax(408)777-3313
CUPERTINO
-� Building Department'
JOB a73 r�t�n DRES PERMIT# 0
OSNNER'S NAIv¢: PHONE# 65 9
GENERAL CONTRACTOR: FAAX#
am not using any subcontractors:G 'y �O n j
Si tune Date
Please check applicable subcontractors and complete the foUowin information
SUBCONTRACTOR BUSINESS NAME BU51 v ESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring:Carpeting j
Linoleum/ Wood
f— Glass/Glazing
• Heating - -I---
Insulation
Landscaping —
Lathing
I i
Masonry
Ornamental Sheet Metal
Painting/.Wallpaper - ----�
Paving —
Plastering
Plumbing —
Roofing '--
i
Septic Tank
Sheet Metal -^
Sheet Rock
Tile
7
Owner/ ntractoi Signature d� ab�
/ Community Development Department
Building Division
• ,;� City of Cupertino
10300 Torre Avenue
OCITY 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.
a
Homeowner's Name: f) at- Gk.
job Site Address: F-,73
Roofing Company Name: ��t,�
A plicant's Signature: Date:? p y
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF 6 s 73
CUPEkTINO PERMIT APPLICATION FORM
APN# Date: _.7Z0
Building Address:2/73
Owner's Name: &� Phone#:
kJ ,CP cYrw�� 7
Contractor Phone#: License#:
Oealoir� Gsv `2 �-sS� /
Contact: n Phone #: � Cupertino Business Li c nse#:
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 ❑ Provide I.C.B.O. Report It
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
7-10 TlL -V &,,P. CL dd LL
an. yr eL,�
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are an restrictions: i5
Cost of project: Type of Construction: Occupancy group:
7 7,50.
Qty. if
Applicable 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
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