03090113 tCrry OF CUPEWrINO rt+^*v:`Ekaz ? aka : < *aifi tilwtt�gnt ..tQVt+, a;�.::
BUILDING DIVISION PERMIT WONT INFORMATION :4
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BUILDING ADDRESS: PERMIT NO,3 0 9 0113
495 GLENCOPs DR.
OWNER'S NAME: PERMIT ISSUE DATE
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NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
CJ o 0
ICA, LICENSED CONTRACTOR'S DECLARATION Job Description
O
4 u r 1 hereby affirm that 1 am licensed undo provisions of Chapter 9(commencing p
�c with Section 700D)of Division 3pf On,BuxinesW Professions Code,and my license is
-�„ in mumrcda Tref IT' 7 4eo REROOF /
It3Z License Claz Le.,
ore gr1t^y_�amrEC v z CONTRACTOR: PEDRO LOPEZ CONSTRUCTION
-E� ARCHITECTS DEC RA ION j
I m a I understand my plans shall w used as public records
>yO O
'a.p� Licensed Prufcssioord
OWNER-BUILDER DECLARATION v
aY 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following Mason.(Section 703L.3,Business and Pmfcssiom CWc:Anyury orcounty
Aww which requires a permit to construct,alter,improve,demolish,or repair any structure
A
prior to its issuance.also requires the applicant By such permit to file a.tigned statement
�othatheislicensedpursuanttotheprovisionsofducContracmrsLicenselaw(Chapter9 Sq.Ft. Floor Area Valuat? 00
EI— '
(commencing with Section of Division 3 of the Business and Pmfcssions Code)
59 shat he is exempt Ncrtfrom and the basis for the alleged exemption.Any violation of
Section 1033,5 by vry APPBcanu for a permit subjects he applicant to a civil penalty of 3�SBd0I`LDI$3et00 ._ Occupancy Type -_--
not mart Nfive
an hundred dollars($5(Ok — - -
El 1,As owner of the property,or my employees with wages as dreir solo compensation,
will do Ne work.and the structure is not intended w offend for sale(Sec.1064,Business
and Pmfcssions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds of improves thereon.and whodoes such woh himself or Wrugh his 305 - FRAME
own cmployea,provided that such impranmenu are not intended or offered for sale.lf. 307 — INSULATION '-
improvementhowevertthebuiWingoris sold bei thin one r of completion,the owner
burdenbuilder will have the burden of year
ving that M did not wild or impronc for purpose of 601 — ROOF TEAR OFF
solea.
❑ 1.as owner of the property,am exclusively contracting with licensed contractors to 602 - ROOF PLYWOOD NAIL
consumer the projces(Sec.1B66,Business and Professions Code:)The Conuacuori Li- 603 — ROOF BATTENS
cense law does not apply to an owner of property who builds or improvea theroun.and 604 - ROOF IN-PROGRESS
who commat u
s for such projecwith a conuaclor(s)licensed puvuano the Conuanor'a
License law.
❑ I am exempt under See. ,B&P C for this mason _
Owner Data
WORKER'S COMPENSATIONDECLARATION
Ihereby affirm under Penalty of perjury one of the following declarations:
1 have and will maintain a Cerificaue of Consent to self-insure for Worker's Compere
cation,as provided for by Section 37W of the later Cede.for the performance of the .. -. ..
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance.as required by Section
37W of the labor CMC.for Ne performance of the work forwhich this Permit is issued.
My Worker's Compensation Insurance carrier and\Po'l'i'cy number am:
Ca 'er. IfOQ� O�CI lm� PoQbbe- _
CERTIFICA O E%EM MON FROM WORKERS
COMPENSATION INSURANCE
has.)(This section need not W completed if the permit is for or hundred doll..(S KXB
err
1 certify that in the Performance Of the work for which this permit is issued.I shall not
employ any person in any manner so as in become subject to the Workers'Compensmion
laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Ccnifica¢of Extra Prion,you should
become subject Lo the Worker's Compensation provisions of the labor code,you must
D z forthwith comply with such Provisions or this permit shall be deemed revided.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I'nr the Performance of
the wor
Ya k for which this permit is issued(Sec.3091,Civ.C.)
10 Lender's Name
Z,z Lenders Address
J O 1 minify that I have rad this appliatirn and mate that the above information is
i F emnct.I agree m comply with all city and county ordinances aW SLAM laws relating to
Z) building construction,and hereby Authorim represcritiocs of this city to enter upon the,
W shove-mcmiuncdptopertyst for i expenses
pon,awhich ms
y y (We)agree m save,indemnify and keep harmless the City of Cupertino,gainst
N lieemstes,judeof the
and ofPcnsawhich may in any way accmc against said City /
z in eonxquenec of the granting of this permit. 4Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE PtfULATIONS.
attrn anoCunlrACAm Re-roofs
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roo(
Willy t applicant or future building e.Chapter
store or handle HeAlth amaee material
as de.Sed io the Cupertino Municipal Cede Chapter 9.11,and the Health and Safety
Code,Section 25512(a)?
C]Yet KN. All roofs shall be inspected prior to any roofing material being installed.
Will toe,applicant or future building Occupant axe a If a roof is installed without first obtaining an inspection,I agree to remove
PP s p a Air Qu or devices which g
it haeardnus air conmminan¢az JcfincU by the Bay Arca Air Quality Management all new materials for inspection. I
Turin?
❑Yes FI Nu
1 have mM the haaaNrv'ss materials requirements under Chapter 6.95 of the Califrr
niceHealth&SofctyCode.Sce6ufs25MS,25533.d255M 1undersuMthu ifd, wildin
OC gg i 6 _0 3
Jdxa nod Curtcntly haze a tenant.Nat it is my respur¢ibilitY w noul'yy dwcupant rf Nc
nequinmcgk which mug the met fin or As issuance oraCenmcmcor Aeu ancy. LA
1SignatArf of Applicant Date
rte, �L ncdagcm Date All roof coverings to be Class "B°or better
Community Development Department
Building Division
(pR t City of Cupertino
R r 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
�'�O Fax: (408)777-3333
UPEBuilding 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 comIlly with the above stated policy on re-roofing.
Homeowner's Name:
Job Site Address: O It
`
Roofing Company N erA✓ Lolk z e 7 ¢.
A phcant' S�-(s(Signa} e: Date6-0 3
\h/gWIX�
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINOOv 3 o
CUPERTREROOF INO PERMIT APPLICATION FORM
APN# Date:
9- /6-63
Building Address:
10'Y C C vt e 11 . e y- 4 4 0 C14 .
Owner's Name: Phone#:
9111 44r b CISS) 996 - -756z
Contractor: Phone#: License#:
Qe.ePru LD z 408 �I7Z-lE97 9'? (;.q
Contact: Phone#: Cupertino Business License#:
Pccl�u l L Z 4of;) - 1 C q
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles Or' 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 Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
Residential ® Commercial ❑
Fire Zone: s o [� Confirmed with PI ng t. if
there are an r ricti s:
Cost of P oject: Type of Construction: ccupancy g oup:
-00
Qty. if
MA li I Fee ID Fee Description Fee Group
BPERMFEE BldgPermit Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
Z 310
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