04090023 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT �kCONTRACTOR INFO�M,ATION -
BUILDING ADDRESS: DUBOIS ROOFING INC PERMITN0.04090023
OWNER'S NAME: PERMIT ISSUE DATE
0
NE: SANITARY OL N0.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
a�rOp LICENSED CONTRACTOR'S DECLARATION Job Description
❑ I��aS5ryryBtoy affirm Nat I am licensed on
visions of Chapter 9(commencing P
zW with Segy3d7Q70)of Division3oftheB. Pr ofessimucesk.andmylicciscis
^�� infull rclood, o �� 2 0 T/O EXISTING SHAKES-INSTALL
o n? License Cress Lic,p
4 Dam Contractor- NEW 30 YR ASPHALT ROOF
IT
ARCHECTS DECLARATION
�y .4godand my plans shall be used as public mcmda
7yV
u Licensed Pndcssianel \ Y
OWNER-BUILDER DECLARATION V
<I I hereby affirm that 1 am exempt from Ne Conuactors License law for the '2z
00 following mason.(Section 7031.5,Business and Professions Cade:Any city or county
K$� which requires a permit ha consumer.alar,impmve.demolish,of repair any structure
_ii poor m its issuance.also requires the applicant for such Permit to file a signed statement
r< Nat he is licensed pursuanitopre provisiomoftheConimcmrsLlccnse Law(Clogar9 Sq. Ft. Floor Area Valut 350
xFn (commencing with Section 7000)M Division 3 of the Business and Prefessiom Code)or
i $ Nm he is exempt therefrom and the India for the alleged exemption.Any violation of
Seed.7031.5 by tory applicator for a pemtit aabjeets 0.appRcent to It civil panalty,of APN Number Occupancy Type
not mom than five hundred dollars(55WL
01,as owner of Ne propcny,or my employees with wag.az their sol.compcnsatinn, 32609056 . 00 .
will do the work.and the structure is not intended maffered for sale(See.704,1.Business
and Pmfessiom Cade:The Conuactaw Ys License law does nor apply to in owner of Required Inspections
progeny who builds or improves thereon,and who does such work himself or through his
awn employe.,provided that such improvements art not intended or offered for sale.If.
however,lie building or improvement is sold within one year of completion.be owner.
builder will have Be burden of praying that he did not Mild or improve for purpose of
mile.).
O I,as owner of the property,am.dusively contracting with licensed contractors to
comwet the project(Sec.7064.Business and Professions Cade:)The Convacmr's Li.
came law does not apply to an owner of property who builds or improves themes.and
who contracts for such projects with a comrazmr(s)licensed pursuanu.the Ciu uactors
License Law.
I am exempt under Sec. ,B k P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,one of the following declarations:
1 haw:and will maintain a Certificate of Consent o self-insure for Worker's Campcm
retia.,.provided for by Section 37M of the Latour Cade,for the performance of Om
work for which Nis permit a issued.
I have and will maintain Worker's Compensation Insurance,az required by Section
37W of the Labor Code,for the perfarmance of the work for which this permit is issued.
My Worker's Compensati3Oam once carrier and Policy number ase:
Gamer.SriF f e T,,.)v-Ll Policy�d.: l ta7 �;`Lr OS
CERTIFICATEOFEKEMPION FROM WORKERS'
COMPENSATION INSURANCE
(This rection need nm W completed Kthe permit is for one hundred dollars(SMD)
ass.)
1 certify Nat in the performance of the work for which this Permit is issued,l shell not
employ any person in any manner so az to become subject o Be Workers''Compensation
Laws of Califarom Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccrtifcae of Exemption,you should
become subject to the Workers Compensation pmvisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall h deemed revoked.
Z CONSTRUCTION LENDING AGENCY
j-. I hereby efr m that there is a construction funding agency for the performance of
O: 7 the work for which this permit is issued(Sec.3097,Civ.C.)
tL10 Lender's Name "
lander' Address
U I
U Q certify Nat 1 have mad Nis city
and coup and sere that 0.and
someshowl information muting to
t2.t" cortex 1 agree ct comply with all city and county eminenceswerof and sure laws relating N
U building construction,and h.pebyauthosvemoses. ides of this manor upon de
r C. shove-(We)agree
to
for inspection Purposes.
C. (s judgments,
agme to cove,indemnifyexpenses
and keep may
in m the City of accrue
against t
U i,iZ in consequence
eofthecodtsandof this cswhich may in any way accrvc against said City d
UZ Aconsequence of DERST ingot this permit. s
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N INT Issued by: Date
SOURCE RE�uL'ASTONS.
���� 9 7y Re-roofs
SStgna�f Applicam/ wcmf ted
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future building occupant slope or handle W/mdous material
az dcMed by the Cupertino Municipal Code.Chapel 9.12.end the Health and Safety
Cowl..Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
[I Yes pro
Will the applicant or furore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit ha>ardous air contaminants az d.Gned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �/ f
Io&haw Safer thehaamdou a25505materialsre33 and nts 5534.1rChaper .95 tautif the birWing
for
niaHcalN&Safny Codc,S¢do.2550515533 and 255J4Junderstand Netifthc building
does nmermenlly M1ace nem.Nvt it is my rodponsinilily m nodly ah.¢cupanI of ib \
aquiro en astlnmetpoortoissuanceofaCertir.eofaeurpor SignaureofApplicant Dae
J O
e armori>aa as DataAll roof coverings to be Class"B"or better
CITY OF CUPERTINO
5 of 5 PERMIT RECEIPT OPERATOR: suem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32609056.00
DATE ISSUED. . . . . . . : 09/07/2004
RECEIPT #. . . . . . . . . : 26941
REFERENCE ID # . . . : 04090023
SITE ADDRESS . . . . . : 20800 HOMESTEAD RD # 3
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PROMETHEUS PROPERTIES INC
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : MARK DUBOIS
CONTRACTOR DUBOIS, MARK LIC # 20514
COMPANY . . . . . . . . . . : DUBOIS ROOFING INC
ADDRESS . . . . . . . . . . : 99 DUARTE AVE
CITY/STATE/ZIP . . . : FREMONT, CA 94536
TELEPHONE . . . . . . . . : (510) 793-9760
OEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 16, 000.00 234 .36 0.00 234.36 0.00 ,
BSEISMICRE VALUATION 16, 000.00 1.60 0.00 1.60 0.00
TOTAL PERMIT 235.96 0.00 235.96 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ _________-__-_____
OTHER 1334.30 VISA
------------
TOTAL RECEIPT 1334.30
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM Ol/b906�3
N# 2 a 6 c/ A� Date
V (�
Building Address: 3
208M
Owner's Name: Phone#:
(o✓I.te'F�'Nev " fined— /wt bSo- S `Ib
Contractor: Phone#: T,icense #:
SID -10) 3 9.�7 6 0
Contact: Phone#: Cupertino Business License #:
11/1h2(� �u0)
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
>p 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:
b Description:
a r OFF IST-,,J 51.,gices 1 -1,1L, os3 OuSi-4ZC loeW 3U VfAf aVF 'I(" JF
Residential ❑ Commercial T� tN�T� EX'S'rNc� C GJF ,
Fire Zone: Yes ❑ No ❑ Confirmed with Planni c t. if
there are any res tons:
Co ^"_*� e of Constructs Occupancy gr 7
ps
3.i C)
Qty. if
Appl 'ab)G I 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
•
Community Development Department
{ 3 Building Division
rr _ City of Cupertino
{ 10300 Torre Avenue
Telephone: (408)777-3228
? CITY OF Fax: (408)777-3333
UPEkTINO
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 Y4" 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: jv-' �,evs ProQatT/ES, /wC
Job Site Address: g00 f" �7_e-YZ
Roofing Company Name:
A plicant's Signature: �f'' Date: g �/
® Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
• Telephone: (408) 777-3228
Fax: (408) 777-3333
Building Department
REROOF TEAR OFF POLICY
1. You must schedule an inspection for the tear off the day before
you wish the inspection to be made. The procedure is to call the
Building Division (408) 777-3228 between the hours of 7:30 a.m. and
4:00 p.m. to request a next-day inspection.
2. When the roof is torn off, the nails have been removed or driven in;
• and all of the dry-rotted wood has been replace, you must call the
City Building Division. An inspector will be there within one hour.
There are special hours for this service: from 7:30 a.m. to 10:30 a.m.
and 1:00p.m. to 3:30 p.m., Monday through Thursday and from
7:30 a.m. to 10:30 a.m. and 1:00 p.m. to 2:30 p.m. on Friday. (Note:
Building inspectors are on lunch break from 11:30 a.m. to 12:30 p.m.
and will not be called during that time. City Hall is closed between
12:00 and 1:00 p.m. daily.)
3. If you call for a tear-off 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.
Greg Casteel
Building Official
Revised 8/13/04
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