04100004 CITY OF CUPERTINO +.+ '• yr '- �'" _ _
BUILDING DIVISION PRRMIT CCONTRXC'04'QR"NF,0RMATIONv,.
BUILDING ADDRESS: DUBOIS ROOFING INC PERMIT NGO 4100004
0800 HOMESTEAD RD 4 12
OWNER'S NAME: PERMITISUEDATE
PROMETHEU
ONE:
SANRARY0. CNTROL N0.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO _
BLDG ELECT PLUMB MECH
O Z LICENSED CONTRACTOR'S DECLARATION -' Job Description
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�w 1 hembY )of but I am licerssed unJer provisions of Chapter n(rommense is -
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;„ inronfp deffect�Z44 ✓ SI 3o I ---- REROOF W/ASPHALT
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£'s ARCH; C-RATION
Sy of< 1 un rkumd my plans s az public Cards
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o� Liccnuil Pm(cssianal
5 OWNER-BUILDER DECLARATION
1 hereby affirm Nat 1 am exempt from the Contractors License Law for the --
p o following mason.(Sectun 7031.5,Business and Pmfcssions Code:Any city or county v
k m_ which requires a permit to construct.alter,improve,demolish,or repair any structure
y¢i pnor mils issuance.also requires the applicant for such permit to file a signed statement -
- 1< that he is licensed pursuanoNcpmmNe
visionfContfzctorLaw Sq.Ft.Floor Area Valuatwn ._.
y~� tt
(commencing with Section 7*Xhof Division Sof the B usiass and Professions Cone)or .
Nat he is exempt therefrom and the breis for she alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 24&Daftoero0 Occupancy Type
not more than five hundred dollars
I,as owner of the proles,or my employees with wages as their sole compression,
will do Ne work and the Susane,is not intended or offered for sale(See71146,Business -
and Pmfesme"Cade:The Connaemra Llama taw dam not apply m an owner or - Required Inspections - -
prepenywho builds at improves themmn,and who daessuch work himmlfor through his -
Ownemployees.provided Nat such imprevementa are not intended or offered for sato.if. -- - - '-- -
--
however.be building or orpronment is said within one year of Compkian,the owner-
builder will have the burden of proving Nat M did not build or improve for purpose of
sato.).
1,as owner of be pmpcny.am exclusively contracting with licensed eontrac.to
constmet the project(Sec.7814.auxins and Professions Cade:)The Conoactar's Li
me Law data not apply W an owner of property who Wilds ar impmm thereon,and. '
who contracts for such projects with a Canniemf(s)licensed pursuant to dte Contractors
License Law.
❑1 am exempt under Sec. .B d:P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of the following declarations:
I ban and will maintain a Certlfieate o(Consent to self-imum for Workers Compcm
sation.as provided for by Section 3700 of the Labor Code,for the performance of the - - - -- -
waik(a,which this permit is issued.
❑1 hoc and will maintain Workers Compensation Insurance.as refund by Section
3700 of be labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insunnee carrier and Policy numMr art:
STnC2 FJ f.y c( "/Policy No:Lice z 3z—07
J CERTI MMON FROM WORKERS'
COMPENSATION INSURANCE
(Thixsection read not hecompleu:d irthe permit is formic hundred dollars(51010)
or less.) I .__
I certify that in the perfnrmancc of the work for which his permit is issued,I shall not
employ any person in any manner an u to become subject o the Woder'Compenution
Laws of Califomia.Dam
Applicant - -
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Ne Labor Code,you must
.JZ forthwith Comply with such provisions or this permit&hall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-. I hereby affirm that Vert is a eonsuvcuon lending agency for the performance of
C4 7 the work fur which this permit k;issued(Sec.3097,Civ.C.)
U C) finders Name
D. Lender's Address
U D 1 certify that 1 have read Nis application and sort that the above information is
corlCCL 1 agree to comply with ill city and county ordinanees and start laws slating to
p U building construction,and hereby autborim reprete lsoims or Nis city to enter upon me
1 shove-mentioned latterly for inspection purposes.
(We)agree to save,indemnify and keep hamless the City o(Cupenina against
f' , liabilities,judgments.costs and expenses which may in any way accrue against said City /
U Z in eonxquenee of the graming of this permit. \ //
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE ATIONS. /// -
gr i�OA/0a1 Re-roofs
Si tum ofA h a�nUCo0.1., m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or
future building occupant score or handle haimalm s material
az defrted by 0c Cupenirm Municipal Cmdc.Chapter 9.11,and tW Health and Safety
nue.Scenes zss3z(a>7 - All roofs shall be inspected prior to any roofing material being installed.
❑rat pAK
Will the applicant or fretum Wilding Occupant use equipment or de.ieca wh
ich If a roof is installed without first obtaining an inspection,I agree to remove- -
emhba,som.,at,Contaminanta defined by the Bay Area Air Quality Manegcmcnt all new materials for inspection.
Disaic0
❑Ycs ❑Nu
Ihavc rest cook hc,Secuusm 5505, s33 and25N.Itquinancres Chapter 6.95 if the Califon
ria Heslih&SafetyCode.Seeuons155(ials re33and1553n.1 understand N5 of
Wilding
Joys not curmmly ha�ra tenant,that it h my responsibility m naily the occupant of Nc
require I�iLLSaWmelpnormi...ofaCcnirmammfU P x Signature of Applicanta[ '
Owner tar authori'reJ agent O „e All roof coverings to be Class"B"or lar
�., Community Development
130 Torre Avenue
COY Cupertino CA 95014
'
Telephone(408) 777-3228
CITY Of Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRE�S: PERMIT #
Z� o� ti,-SrcE� C� �`I 1 ooao L
J^�GJ
OWNER'S NAME: PHONE # 600 � S g�-S3oa
GENERAL CONTRACTOR Du(3,, we FAX # S'ro 75;3 IF O
1 am not using any subcontractors:
Signature I Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
qUPEkTINO
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: Poo Rpaq ri naLp 3
Job Site Address: 20 8 00 �a -tiQ aSTP4o� �p uc7 //
Roofing Company Name: �� ms's t��S,N ^ C_
iPtcant's Signature: ' �/� Date:'e
Building Official
Revised 1/30/03
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=� CITY OF CUPERTINO o
REROOF
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1 ' CUPEkj1NO PERMIT APPLICATION FORM
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'RPAPN# 32 CS/ B Date:
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Building Address:
Zo o - W nXn N i sC-. ct cL —s 13
Owner's Name: Phone#:
(o✓ te.f( 2U � �Fl //cG U50- SL.,
Contractor: Phone#: '.icense #:
7.x(5' ; � �{-�•,,� ,Slo �i� 3 �;7,F�C� ,�_ SIL 30�(
Contact: Phone#: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Cl Asphalt Shingles X Asphalt Shingles
p Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings 9 ❑ Provide I.C.B.O. Report#
J To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
14pob Description:
-las OFF E�rsT 5P-sTi-t-i CW " 0s3 Aveld 30 (fwqsAicr,,3voe
Residential ❑ Commercial —r'o Vwt-Tc to E S'1, vG r ('oF .
Fire Zone: Yes ❑ No ❑ Confirmed with Planni J e t. if
there are any res i tons:
Co - *� e of Constructs Occupancy gr r 7
S
-2-00
Qty. if
A l' ab e 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
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