05060187 CITY OF CUPERTINO �'
BUILDING DIVISION PERMIT , GONTRAGroRINFQRMATION
BUILDING ADDRESS: WOODS ROOFING PERMIT NOO S O 6 O I S 7
Ig Rc)T,TV�4FAT) IN
OW NER'S NAME: PERMIT ISSUE DATE
ANGELA
41
ONE: SANITARY NO. CONTROL NO,
(831) 637-5976
ARCHITEC,'ENGINEER: BUILDING PERMIT INFO
BLDGEIFGr PLUMB MECH
uo0
LICENSED CONTRACTOR'S DECLARATION O O O O
:u C I thereby afftrm tat I am licen"cd under provision of Chapter 9(commencing Job Description
�zbtu wit Sochon7aDB)of Division 3 of Ne Business aod Profcasium Code,and my license is
n 3 F in inn mrte,nd t7
3p� License CIAx`34 Lte,g 2 I3 1 REROOF W STEEL TILE�{-�,; LL
Lip Dam ��cut= r p L� �aL t.•�.�
n�t,Je ARCHREC'S DECLARATION
< I understand my plata shall be mind as public records
;;y Licensed Professional .2005
3 OWNER-BUILDER DECLARATION
I hereby infirm to 1 am exempt from Me Conlracmfs License Law for to
p 0 following moon.(Section]fD LS,Bulinus and Rofcssinns Code:Any city or county Irk II FI Q(' (��� 1' n
k m which myuiru a permit m cnn"wcl alter,improve.demolish,or repair any nmcwm n II I I I r I I I ' �=.7
prior nits Issuance.alw mquims the applicant for such Permit to rile a signed stamm nth v u t ov u u v
< tatheislicensed pursuant toteprovisions OfMeConnector's Lienulaw(Chapter 9 Sq.Ft. Floor Area Valuation
YFa (commencing with Section 7")of Division 3 of the Business and Prafueio sCMC)or
i R$ Nat he is eumpt tetefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3 GiTNG,0"erO 0 Occupancy Type
not morn Nan five Wormed dollars(g5W).
❑1,u owner of the property,or my employcu wit wages u their sole compensaslon,
will do the work,and Ne swmum is not intended or offered formic(Sem.7D44,Business Required Inspections
and Profession"Code:The Commences Licen"e Law docs not apply w an owner of 9 P
property who builds or improves Neuron,and who does such wark himself or Nmugh his
mvn employcu,provided Nat such improvementsare not intended oronered formic.If.
however,Ne building or improvement is sold within one year of compledon.Ne owner.
builder will have the burden of pm,ing that he did not build or Improve for purpose of
sale.).
❑1,a owner of to prapcn,am exclusively contracting it licensed conuacte.m
construct the pmject(Sec.7(144.Business and Profusions Code:)The Contranor's Li.
cense Law doe,not apply in an owner of prapeny who Wilds or Improves tenon,and
who contracts for such projects wit a contractor(s)licensed pursuant to the Comeactoh
License Law.
E]1 am exempt under Sec. B 6 P C for this mason
owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pmtalty of perjury one of Ne following deductions: -
1 have and will maintain a Cenifeam of Consent to self-insure for Workch Compen-
sation,u provided for by Section 37M of Ne Lawr Code,for dm performance of Ne
work roc which this permit is issued.
have and will maintain Worker's Compensation Immune,u minims!by Section
7 W of Nc Labor Code,for dm performance of the wart for which this permit is issued.
My Warkefs Ca-m-yyppecstsadon Insurance Cartier and Policy number art: I
Cartier. S"] t^'_� PolicyNo.: s' 0��lgf_L
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thu scerino need not kcomplcwd if Iw permit is for one hundred dultars(SI W)
or tau)
1 mr ify Nat in to performance of thC work for which this Permit is issued.I shall oat
employ any person in any manner m u in become subject o tc Wo,keri Compcoommo
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to to Worker's Compensation provisions of Ne Labor CMC,you mind
.JZ foMwit comply wit such provisions or his Permit shall be deemed mvoked.
zCONSTRUCTION LENDING AGENCY
Ihereby&Mrm that Nert is a Construction lending agency for the performance of
2' tc work for which Nu permit is issued(Sec.309],Ci,C.1
�W Q lender's Name
.7 Z Lcrulmes Address
U O 1 certify Nat 1 have read this application and sum Net Ne above information is
ly H Wmcn.1 agree to comply wit all city and county ordinances and state laws relating to
p U building construction,and hereby autori,e represemuiws of Nis city m cmc,upon On,
Y'a above mentioned properly for iupecuan purposes.
(WC)agree to save,indemnify and keep harmless to City of Cmpcnino against
Iiabilides,judgments,costs and expenses which may in any way new against mid City
UZ in consequence of Ne granting of this permit.
�—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL JJJJON-POINT Issued by:9 Date
SOURCE7GUL ,Tlf1NS.
(li—i��� / aS Re-roofs
Signature of Appli HAZARDOUS
Date
H
HAZARDOUS MAng Occupant
DISCLOSURE Type of Roof
Will Ne,Carr or(mune wilding occupant mom or handle Heart and
u defined by tc Cupenina Municipal Cade.Chapter 9.1],and Ne Hca1N and Safety
Code.Sec Bon SSR(ar! All roofs shall be inspected prior to an roofing material beim
❑Ye, P P � Y g g installed.
Will to applicant or future wilding Occupant rose equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
it hanardous air cwtmminan s as defined by Ne Bay Area Air Quality Management all new materials for inspection.
❑Yes ❑No
Ihawread Nelw iwmamrialsmquim=ntsundcr Chapmr6.95ofdm Califon
d'..
Calc.Scniats2S505.255J7 erW]5534.1 understand Nui(IM wilding C9
dors not cwcntly haw a mount Nat it u my mapomtllby m notify the cupen nr dm - -
rcyuirtmcnmHd' m cmctpdor umceofaCCNfinmofAccu>n Signature of Applicant Date
Owner or authorircJ age C0 L All roof coverings to be Class "B" or better
Obi;W Y005 22:43 5105383282 LEGALITIES INC PAGE 01
. 10100 Torn Avaale
ClyadusCA WO
Tobe(403)777-022.6
CU*t INO Fa(")7"-3333
Bu*Idv Department
JOB ADDRBS8z
Ri1STT N
OWN&R'S NAM& PHONE'#
G131V$RAL CONTRACT R: E FAX N
I =not using any subconlzactaas, vs
Please shack livablesubcorttraators and complete o inforulatiurr Daae
ia SUBCONTRACTOR BUSINESS NAME I BUSINESS LICENSE #
Cabinets&Millwork
Cement
Fwahing
Electeical
87a:avation
Cwpeftg
Plovtittg
Ltnolem/ Wood
Glass/G
®
Heaft
Iasutletiaal
Pu1B
maxwn
L '
OM=Wnttal Sheet Metal
-Pain / Wall
Pa
P1
Rooft
Se Tank
Sheet Metal
Sheet Rock
Tile
" �" Owns'/Con Signattire Date
Community Development Department
Building Division
j n City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E T I N 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$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: aY4Z(� � L� 4
Job Site Address: G —
Roofing Company Name: orzP 5I CT
q
Applicant's Signature: Date: �a O
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
REROOFCITY OF
S v 6 �1
�CUPERTINO PERMIT APPLICATION FORM
APN # 3 � 2 �° O l 5 Date:
Building Address:
//
Q
/ _
Owner's Ne: Phone#:
a�
Contractor: hou #: License #:
S YUP- /, 0r03 zS ! 3
act_ Phone#: Cupertino Business License#:
o$ i, 0 S - 3//S 2_0810
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-----3 Provide I.C.B.O.Report# N 23
N& To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: -Flo C3J ` 6M,4 A-_ff. n--4/4"96'�6C4Qp 0&Q Zt&
Residential �n_ Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: 6o Type of Construction: Occupancy group:
12, Ovv
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