05030175 CITY OF CUPERTINO'
BUILDING DIVISION 'PERMIT - CONTRACTOR IN'EbRMATION h
x
BUILDING ADDRESS: . PETERSEN-DEAN INC PERMITNO05030175
NEY CREEK PL __
r
OWN
NAME PEWITISSUE DATE
f Eh AadYr tr 1 ai4�r 51f t"yh / Jit .� ti! INr?, - SANITARY 2 CONTROL NO.
11IIa I{19,�r is D,,I ,af ,,r/' ,I f�,y: rG(It . , 1. 510 494— 2
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI4
• o 0 0 0
00 - LICENSED CONTRACTOR'S DECLARATION'
so 1 hereby affirm that I am licenced under provisions of chapter 9(commencing Job Description
;aw with Section]IXXI)nfDivlsion3 of the Business argP utLa Cnde,and myliccnu is
in full forme an f �/0 I
iqb L;m<nl:,cA,a °�--f°i4 ' .il L;r.x o • REROOF W/SPLITAKE TILE
it-, Datc'_�--'�f`
ICLA TION
i < 1 understand my pl a shall he used as public recnNs _
)dU
py Licensed Prefessinnal
S OWNER-BUILDER DECLARATION
a f 1 hereby affirm that 1 am exempt from the Contractor's License Law for the .
:00 following oration.(Section]I13L5,Business and Professions Code'Any city nrcounty -
$� which requires permit h+construct,aI¢ mp dem lih,or repair any structure
�2w prior to its Issuance, Iso requires the applicant for such peoutm file a signed statement
e i ao that he islcnudpursuant 10 the pros or theContractor's License Law(Chapter 9 - Sg Ft.FIOor Area- - ----""----'Valuation------ -------
:I- - (apmmcmming with Section 7000)of Dur.von 3 of the BusinessndProfessions Code)o -II t1t
s
that he is exempt thernifrbroand;the basis for Nc alleged'*mpsioh:_Any violation of I ',1a"t 1- s,!i I! f t
'
Section 7031.5by.any.applicantforapetmitsubjccLWe applicantlo acWil pcnaltyof : I.Fc.._._ =..._
:j not more Nan.Eve hundred delta.($51Td). - 3' ���OO 1; Occupancy Type--- ---'----
a'ff.t.
+ ❑:1,as o-w of the
Beopcut a y c,ployeii with wages as their ale comPmoil li
'll Bothe woeked Nsnuclum rsnot Nrehdcd or offered for sale(Sch.BM Business - --'" _"-- "-- -_"- --'-""'-"'- -"-----------
'Md Pm(eas nn5 COdC:Tile CanlRelors LlaenY Law does act apply t0 an r nccof '' ,%.,,: Reglllred'IDSpCCIlO11S ^r`` P
property hobo ids or mDmves Ne con and�hodoes ch rkh self thro gobs 1
pwn emploYcca pN(Bed Nal Such impryvemenUue ootlnteMc4oraffuedfo aalcaf s _ __ _ __
Phi a,wlN,Wur,Ipl1n�pr Jan df unenl ss i4thad tlR;i year of db plea npu weer }J n1,\ y \ `ice ....'.- 1 ^:i t l r 1"O'.P.O.. .
hptfdcµ411�habe tM buJan df pro n8 Ndf he Np(rot Wild r itfprove for puryme of Ful L jt;'Fall
>
71ID as t the project LNe Sec.ty c los and col act g N licensed mnactor s m r
con se Lathet (Sec.to anBusiness and Professions Code:)The Contractors n ,1A R{�r^ ❑_ Cf 1L r ILLI " t5f
to a of property who builds o Imp o he Nemose and - -�// 2"Tt l I j
cans Law docs of apply
who contracts TOT such pfoleCR w�lla FntNae!pF(,Ul de sed p'i aI ION C t 'tor �
❑Lameempt I&$eF'i e&PC farNismatch
' (tw�I�
tOwi!er.- s Date V �
WORKERS COMPENSATION DECLARATION_-r7_
1 hereby a1Tum under penalty of pe0ury ane of Ne Tallowing declvalions:
f n •. l.: neueef Wok is Compcm'
.s Ihave a e or hinaCcntficam of dirt a scot ,
nfor hick cd.for hiSenidn 37M of Nc Labor Cotlh,for die pctformen<c of the
w
for which Nis pertni4is
1 hwc dnd wll lneititai6 Work t 5 Comisanse0n 1 s kc;'as¢y cd by Scctipn
J'!O(1 oTNClsbor Codc`forN pert mance bfN okfv which th
it is Issued
r fsCd (,ens unit In urehcc canmi'and Pohcy numbcra " .. . ._._ _ .._ .. _.. . - . _ _-_
.' CamcrR-^[NUTM'IIJLfYI•a4r';]Pol cy NtlY/cJ172'�J4J fit-°." - _.. (. 1..,,.: It r1 M!t R'; :.,_,. _ _ - ,.,.iC'!L. : ... . .•.
' 'r? CERTIFICATE OF EXEMPTION FROM WORKERS' c:
Litt a IL ! 60MPEN6ATION INSURANCE',/� 5 r 4 - ? 1 ri 1 r ):
I
m`icesj ` Scali nnccG of ticc p15'sti if iGc lMrmwsiar Oita tiundrcddollers(ut%B _--
ICCnf !tial N fm0c h ork for wit hN it¢t tied lab!!,stat ::: -"_ -oe. _. .__
1
Ir. mPtnY aaY pctaon nasty man c s a;u hbeomcs bl Gso the Wo kcr;Co pcmaiinpl 'i *it it,' ` 1,t, ak>.! {1
I,
U sof FdhfWnsa Dalfl' ' ' .. 1
}s'
To APPLICANTIf otic (nak'PS�Iu Qcmftmc a6Eu I -d you sti iuld ._...._. ..
Z!
braes bleat w the Wpr(ua CotppS s5u n Pm Is 5 of the Ish Ct�ga Y uy
,� fprlf\,ilh<otti�ly wuh su2h provrsmns oath s perm tshall be deemed re ked i`'1 _
0. .. .-...._..__ .... .....I --1 _. _.._.--_._ ...._._.._... ..-_._ __.. .._._ ....._'__
.Uj tD. t*IoIrSaetdlc.l CONSTRUCTION bltdnd AOENCY:i. . .',; ',iter ,I. f:lO
a's.evnl M1erebY affirm Nal Ncrc eacorswnidn lend ngaganuyf-N pe fomarxe 6f: - s..
C:
Y.�✓'
the work for hrth this perstrobism d(Sa X197,CN.'C,)!III '.............
A Lender _. i t t
t.Cnticrs Addmss, I:_ ']141
)sQ L d cast ty NaI I have or ad tors applmaud end stela Nar: c ebo c mforma041 c
�.,r cprtpla'l agree to omplywtb all any andcounty ordinances and state laws relating to; +
U b Id'g constmm)o and hembye Nond<rep c mtmaef Nig city tocntciupon the
aha c me s n d props tya(or Inspc t on purpous -
G tW3)agrcd tnstive^indemMI and keep ha Bi5l dad'Cu)l ofCipenmb against
rn labtllics 7udgmcnu costs;std ckpcnsP wh'chm may nmy ay accmc ag lits!aid City
J z c pscyuCncF of Nc,.a g fI sperms!:
APPLICAN"f QNOERSTgNQS AND WI{ COMPLY lj WITH ALL NON POIN'"r Issued by: Date
SOURCE'Rio TIONS ` r I t • t'- �
rb' se} Yr_sa Re-roofs
ggatr Appcot ea
rar _ -
:I nHA2ARD00S MA`<a R1AL5 DISCLd$URE t '' .Type of-Roof-
7
f ROOF
.a .:;:.W 11 Nc appbgmvfdl b 3;
uildin oENpentamKnr hhndlc hasaNuus matcitalJ ..t.-1I r f -' ...._.t .._.._ LiS. .It-
as d finotl by the Cupdninn M muipellCoda:CMPIc 9 fZ and the Hea1N and Safety
ij
Icru<.,secy�zss3na) »I Na All,roofsshall be'inspected prior toany=roofing;material'being-installed'-
,E] �? n 1 .. 'l.'.ti_1 , C:-.:_ _
Wdl the app! l or fmurc building ac p t use cyulpmenl or de yea which If a roof is installed without first obtaining an inspection I agree to remove
r16iafdus al emuants delimit by the'Amy.Arca qtr Qaauty Manascnume' .,::all:new:materials;for-inspection _..... __ .__
4c+�ycs
1 tf jl rlhayc mad dm Wasp ousmarcrgl¢n7yuircmentsunderCAaple --
naHcalN�sarepCudpShc¢txp z35BS�ss)Sapd us3a lb JerEtaml Ngtdthe hu lNPgt (---���_
P the pot torted! Mase ttenmt Nat) Its nIcI-Pnnip ep.f ehc rcCJpanl nf,N ! �ni/c---Ot�
C rcy fame ka hmust be t Its an C mfcam of QcuP cy __, _
• Signature of Appli nt -of - or b
�---�*— All roof coverings to be Class:;B or better
F ,.l Oweier ur;amb recd aFcm, „Date,:, ,� �
03,15/2005 13:05 FAX 5104949077 Feter6en0ean Z 001
03/15/22005 00:25 5105383282 LEGALITIES INK PAGE 01
S+o- 538- 318'2. -7o�
� Community Devdoymeat
10300 Tmm Avenue
Cwcrdw CA 95014
Telepboae(408)777-3228
ca Fina(408)777-3333
%PEQj1N61.
Building Department
JOB ADDRESS: ;�6 Lf 6 -7 +-Iz� t..( C c.tzl� P I
OWNER'S]`NAME: M�1\e(LG L PHONE NE# 4 o - y -
x GENERAL C0NTR.ACI012: L+9-(S FAX#
,A I'am not using any silbcontrectors: 2.Ga'Yk xihr/cz—
Signature Date
Please check applicible subcontractors and complete the Wq information:
SUBCONTRACTOR BUSINESSNAME BUSINESS LICENSE #
Cabinets 6c Millwork
Ce3hent Finishing
McGtncal
Excavation
Fencing'
Flooring: Carpeting
Linoleum/ Wood
Glass'/ Glazing
w . Heating
liisulation
'Lul3scaping
Lathing
Masonry
Ornannental Sheet MeW
Fainting/:Wallpaper —
Paving
Plastering
Pluanbing: .
Roofing
Septic Tank
She@t Metal
Sheet Rock
Tile
- �
Owner/Co-ritrzCd6r Signature Date
10n8/03
Community Development Department
Building Division
a,9&
10City of Cupertino
300 Torre Avenue
CITY Of Telephone: (408)777-3228
U����I�O 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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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: C�/fna-�� '
Job Site Address: /01/07 � ✓�M' t//���a� Jdt/zx�
Roofing Company Name: aw EF/ n� —
Applicant's Signature: Date: �O 5
® Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
i_RREROOF v S"a 7S
OF
CUPERTINO PERMIT APPLICATION FORM
APN # 3 / 1 Z _ y5�- _ 0 ;;—, � Date:
Building Address: /v 4/D ? ?y f '
Owner's ame: t Phone#:
221, RP C-iq-, 7q 9-377
Contractor: Phone #: License #:
. 9nc, Slo ;44R-11 7
Contact: D 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) Ey4nw 7ti�
Number of existing coverings Provide I.C.B.O.Report# e-.e— Z G S 6 _
)6 To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
obescnp ion:
T�O o S/3 9-daIN tJruse . t�.t..ta." z:o00 ;44-ld.+& t-�'—
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
/ 8' $�0
Qty. if
Applicable Fee ID Fee Description Fee Group
I 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