03050092 CITY OF CUPERTINO 7 ``
BUILDING DIVISION PERMIT 0dN`CRAI`TdRTNFdTtMtl.TTdN'�4:
Bo.
UILDING ADDRESS: _ R E ROOFING & CONSTRUCTIO PERMIT
0300�50092
OWNER'S NAME: PERM15230 CLYDELLE AVENUE 05/20/2003
NE: SANITARY NO. CONTROL NO.
(408) 925-9995
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 M � 0
i00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
? with Sect.7000)of D' 3oftheBusinessasMPfofessiona Code,andmylicenseia
ja� LfeneClass errttt rLie.1 �z1y`)�.. REROOF ������®
q_ License Class
1 F p Date �I- ARCHf1ECTS D /.-
R, ImNcrsond my plans shall housed az.W fc'r rd MAY 3 0 2003
co.
o�; Licensed Professional
S OWNER-BUILDER DECLARATION p�
<E 1 hereby affirm Nal I am ucmpt form the Can nnon'a License Lew for the BUILDING
p O following moan.(Section 7131.5,Bvimss and Professions Cods:Any city or county
29 which requires a permit m consuuct lw,.improve,demolish,or repairmyswctum
prior In its issuance.also mquirex the applicant for such permit to rile a signed statement
.;0
i
that he is licensed Marshall o the provisions of the Comment's Liccvc Law(Charter 9 Sq.Ft.Floor Area 18io
[�O (commencing with Section 71100)of Division 3 of the Business and Professions Code)or $137
$ that be is wa mpt therefrom and the basis for the alleged exemption.Any violation of
Section
more Nan fine hundred dollars($5W).n subjects she applicant m siva penalty of 3 6219 2NOIDtler 0 0 Occupancy Type
❑1,az owner of Ne Property,or my cmploycu with wages as their sole compensation,
will do the work and the structure is not intended or offered for safe(Sec.7W,Business 305 _
and Professions Code:The Crntmemn's Lie.. .Law does not apply M an owner of rE Required Inspections
propertywho builds orimproas lhemon.and whodoessuch walk himselfor through his 307 - INSULATION
own cmploycu,provided that such improvements art not intended proffered forsale.If, 6O1 — ROOF TEAR OFF
however.Ne building pr improvement is sold within one year of completion,On owner-
builder will have tiro burden of proving that be did ret Wild or improve for purpose of 602 - ROOF PLYWOOD NAIL
asts.). 603 - ROOF BATTENS
❑1.az owner of the property,am exclusively contracting with:)Thud eontmces to
copse La Noes not apply
n Businessand
rty who)Wi Code:)The,mmdaemon, u- 604 - ROOF IN-PROGRESS
cense ontr dors not apply b an owrry of property who Wilds or improve thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Conuactora
License 4w.
❑Ivo ucmpt under sec. ,B@PCfor Nis mazon
Owner Dam,
WORKER'S COMPENSATION DECLARATION
I hereby afford under penalty of perjury one of the following declarations: .
1 haw and will maintain a Certificate of Covent to self-insum for Worker'sCompen-
sslion,u provided for by Section 3700 of the Labor Code,for the perf ummee of Ne
work for which this permit is issued.
1 ban and will maintain Workers Compensation Insurance.as required by Section
3o1 the laborCode,for the perfomtanceof On work for which Nis permit is issued.
My Crime ompevationJnsurenucaricrsnd Policy nnumberare: I
Carrier. t•(,3 l Policy No.:M 1 ISI t �7
CERTIFICATE OF EMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thusce ion need not W Completed ifft Permit is foronc hundred dollars($:00)
of less.)
I certify that in the Performance of the work for which this Permit is issued,l shall not
employ any person in any manner an as N Wcomc subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to'hn Worker's Compensation provisions of the IaWr Code,you must
O
4 forthwith comply with such provisions or Nnn
this Pei,shall W deemed revoked.
'ZCONSTRUCTION LENDING AGENCY
(-� N., Iherehy affirm that Nem is a Construction lending agency for the Performance of
F4> the work for which this permit is issTd(Sec.3W7,Civ.C.)
W 0 Lender'a Name
z UMIM's Add.,
U C) 1 cenify that 1 have mad this application and sum that the above information is
F-rom
ly Correct.I all to with all city and county pNinanas and sate laws m
relating �.
DU building conswction,and hth
emby auorim mudvu
presenof Our city to enter open the
move-msnuproperty for impactionpurposes
N y (WC)agree to ,indemnify and keep harnless the City of Cupertino against
ti h save
liabilities,
judgments.coals and a.,..nsu which may in any way accmc agarvtsaid City
nacqucnce of Nc gaming of this permit.
" APP ANyUNDEST
ANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date S —Z
SOUR �aEG�E R I '7 I �D
—ter 2� Re-roofs
Srgnatur ofAppb UConuaeeorpTje
�HAZARDOU MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building wcupant,uore ar handle hanrdous material
az dcrined by the Cupertino Municipal Code.Chapter 9.:3,and the Health and Safely
1dillilkLode,seption 25532(a)7
No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
%0,�n,.r
he applicant or future building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
us air coouarno s az Cold by the Bay Arm Air Quality Mm,mm I new materials for inspection.
Noanhave e Nete.SMM xmamdals mquiremcntsundcrChapmr I atif NeCalsa
dingo''y._ Scaov255n5.355J1 end 25s34.l undcrsune M\vifNc Wildingently have a mam,OW it is my m1okoe ihi:ity m nobly the'ccupant or dm
whip a dbrm anceofaCcnifslgnature of Ap 'cant Dale
once agent Dam All roof coverings to be Class"B"or better
Community Development Department
gg
Building Division
City of Cupertino
10 300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
U P E IST I N O
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.
Homeowner's Name: I'
Job Site Address: 2 14 L)�
Roofing Company Name:_ Il UTA l 1I q 57 1ZU Cil�0
A plicant s Signaturre: i Date �2(I I UJ'
6
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO 6 3 as 6 7 'L
REROOF
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# / 2 _�
5 �2 03
Building Address: 2 I � 1t6 � RO L-0 C),k k bj",
Owner's Name: Phone#:
LW IN yuk - 252- 2���
Contractor: Phone#: i h 0 - 9 ,15 License#:
a0A. (Ne ,
Contact: / Phone #: 4(A- �1 - Cupertino Business License#:
�b�l E �R[t�rux r-7413 20 6 S
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ;K Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles /1IS W U ❑ Wood Shingles
C
Other(Specify) U 9 ❑ 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: p,6 µdlk oii TtN 4 RoX 105TA1L ' z" CDx , 01* PN T
6 P R�n1 n&ir�A1. T L S P li Av( I+t w �S
Residential Commercial ❑
Fire Zone: Yes ❑.No_ Confirmed with Planning De t. if
there are an restric
Cost of Proj t: r ,� U U Type of co c 'on: Occupancy gro
Qty. if
A 1 a 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
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