04100005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT tRONITRACTOWINFORMATI�ON
" BUILDINGADDRE55: PERMIT NO. '
DUBOIS ROOFING INC 04100005
• OW HERS NAME: PERMIT ISSUE DATE
ONE:
SANITARY C N OL NO.
1AR CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB METH
u LICENSED CONTRACTORS DECLARATION _I hcmby affirm that I am limned under provisions of Chapter 9(commencinglob Description
th Scetia g1U)OfDivision3afthaBusness an ofcssimuCodc.andmyliccvcisea ten Tame derramZ oa7 REROOF W/ASPHALT
^ rnacass mcnrds`o
or^ Licensed Professional
3 OWNER-BUILDER DECLARATION
<M 1 hereby affirm that 1 am exempt form the Con antor's Liccnsc Law for the
_ci D following mason.(Section 703I.S.Business and Profesoons Code:Any city or county
K m� which myuires a permit to construct.aper,improve,demolish,or repair any sarcasm
y-'^ prior to its issuance.also requites the applicant for such permit to rile a signed summent
-�< mathcen
c isliwJ purwanuO me provision of Ne Comracmr's License law(Chapmr9 Sq.Ft. Floor Area - Valu 100
xFa (commencing with Suction 7")of Division Of me Business and Professions Code)or .
'd $
and he u exempt therefrom and the bus fm the alleged exemption.Any Halation of
Section 7031.5 by arty splen.,far a permit subjccm the applicund m a civil Penalty of 3 utero 0 Occupancy Type
not marc than five hundred dollars(SSML _
I,as owner of the property,or my employees with wages de their sale compensation,
will do the work.end Ne stncnte is not intended or at far sale(Sec.7064,Business
and Pares this Cade:The Canuactnrs License Law does M1 apply m an owner of - Required Inspections
property who builds orimproves thereon.and who doessueh work himoelf or thmugh his
own employes,provided Natswb impmwmems arennt intended to offered for sale If, --- - - - — _- -
however,she building or improvement is sold within one year of completion.the owner- - - -
builder will have Ne burden of proving Nat he did not build or improve for puMose of
sale.).
I,as Owner of the property,am exclusively contracting with licensed eonuacmu to
cansarn the project(Sec.Wad,Business and Processions Code:)The Conlncmr's Li-
cove law docs not apply or an owner of property who builds or improve Inemon,inti -
whoconuacmforsuchprojece,witha comramer(s)licensed pumuanno the Comncto's
License Law.
❑1 sun..am pt under Sec. B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby a1Bmn under penalty of perjury One of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compcm
lcm/
lon,mi provided for by Section 3700 of me labor Code,for me peAormanm of she
W
for which this permit is issued.
1 have and will maintain Worker's Compensation Wombs,res requited by Section
00 of me labor Code.for the perrormance or the work forwhich this permit is issued
y Worker's CnmpeTviati Insunn/5c canic,.dPolicynyLm/W tam:� I'4 r'C.F✓NOT Poli No: 16 1 3)_S--0�CERTIFICATE OF EKEMPI'10 OM WORKERSCOMPENSATION INSURANCE
fThu section need not becomplcted if t e permit is phone hundred dollars(SIM)
or less.) - -
I certify mat in the perforromm of the work for which this permit is issued.I shall not
employ any person in any manner an as w become subject to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenilleau of Exemption,you should
become subject to the Wankel's Compensation provisions of the labor Code,you muss
.JO fuMwitli comply with such provisions or this permit shall In decreed invoked.
'Z " CONSTRUCTION LENDING AGENCY
[.. I hereby affirm that them is a construction lending agency for thepterearnanm of
x > the work for which this permit is issued(Sm.3M,Civ.C.)
Ctender's Namc
,z lender's Address
U 0 1 certify that I have read this application and sate met in.shove inf.no.hurt is
correct.1 agree to comply with all city and county ordinances and sum laws relating to
CU building construction,and hereby amhonnampracnutives of this city to enter upon the
C
above"mentioned property for inspection pugwses.
(We)agree to save,indemnify and kale harmless the City of Cupcnino al;
ainst
nstN liabiliticajudgmenm.eosm and expevv which may in any way accrue against said City Ir
U ineonscquenecofmc gruntingof)his PermiL 6
LICANT UN RSTANDS AND WILL COMPLY WITH AL N N-POINT 'Issued by: (�' Dale- -�
5 R NS. 9/}
it
Re-roofs
Sipasure of ApplianUConuacmr Date
HAZARDOUS MATERIALS DISCLOS RE Type of Roof
Will the applicam or foible building occupant�m or handle hanrdous mammal
as defined by the Capeninn Municipal Code,Chapter 9.12.and the Health and Safety
code.Sccdun 25532(.)' All roofs shall be inspected prior to any roofing material being installed.
Ya
Wit]the apphnntzard0`7mwm
building n de =avant me equipment or dentes which
finIf a roof is installed without first obtaining an inspection,I agree to remove
mil hazardous air contaminants ed by the Bay Area Air Quality Management all new materials for inspection.
Clinic,'
Yes
I have read the by nusmamrials myuimmcnm under Chapter 6.95 of the Glifao-
nix Health&Sammy Code.Section 25505.25533 and 25534.1 undeuund thaztribe building
doe not currently hast a te ant,mss it is my responsibility m notify occupant of the
requirem iswhic mdpnor issuarmOr.Cerdfia¢of cup =y Signatuieo Applicant Date
Owner nr modand agent 0 D,l� All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
' Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESPERMIT #
SoosT ewQ QD Cu TjNo � b `l / o b b S
OWNER'S NAME: PHONE # {1,o SSG S3oo
GENERAL CONTRACTOR: b„Rors FAX # Sro 79'3 5'5-0 Z
I am not using any subcontractors: rD / D y
Signature ate
Please check applicable subcontractors and complete the followinginformation:
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
V� Tile
fo t 0
Owner/Contractor Signature bate
Community Development Department
�""`�;, Building Division
9 , _ City of Cupertino
{ 10300 Torre Avenue
" Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEI\1INO
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: `�` n"",-3,e ')S
Job Site Address:
Roofing Company Name:
_D-113o'f g2r—, �J4 GlaC
A plicanYs Signature:'%Gl��il� � Date: ed i
Greg teel
Building Official
Revised 1/30/03
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CITY OF CUPERTINO
REROOF
e �—o
(-UPEkTINo PERMIT APPLICATION FORM v
VIVAPN# Date:
Build i^n�
L�g Address: 1
0 6M i?_b C,�, L1�n_—t n/1 t �l S PS ci
Owner's Name: Phone#:
Contractor: Phone#: ",icen�s7e #:
�. (5 i nor- ,�-. fuc
SSb U
-1q3 9;�,� Q. _ . I _ Soy
Contact: Phone#: pertino Business License#:
El/1/!2(� a neo 5 Slo -VA - '[ g Oc( Cu
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles �' Asphalt Shingles
'X' Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings { ❑ Provide I.C.B.O.Report#
.l To be Removed ❑ Provide Mfgr. Installation Specs.
,mgi Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
ob Description:
Tear oFF EXISTrj 5 Ices PsTA-u eco �i, os3 �Ns,-�u ,veld 3o ewasA4c of
Residential ❑ Commercial —fes V' ,v TCAl� N,� C bJF
Fire Zone: Yes ❑ No ❑ Confirmed with Planni e t. if
there are any res tons:
^n^*=� e of Constructs Occupancy grq& ^ 7
000
Qty. if
A 1 ab e 1 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
42 -72-