04100007 CITY OFCUPERTINO � "^ "``
BUILDING DIVISION: PERMIT CONTRACTORINFQRMATIQN a _ ?'•.:
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BUILDING ADDRESS: DUBOIS ROOFING INC PERMITND04I00007
OW NER'S NAME: PERMIT LbUEDATE
PROMETHEUS
ONE:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION - - - Job DOSCr3pIlOn
u❑ I Mreby affirm that I am li¢nxd under provisions of chapter Y(commencing _
i W with Scotn 000)uf Oivision3 or NCBusi ess. Bre heinous Codc,and my license is
"or'n in murn,�pS7ait fREROOF W/ASPHALT
igz teen, G ni LK.a
�Fp Dam J Contractor
-pspis R ITEETS DEC LAR ION
C, k/I underaut '�C IM used is p>=� mcords - --
�yU —
i:o Licensed Pmf an
3 OWNER"BUIIDER DECLARATION'
.i Y 1 .by
affirm Nat I am exempt from dis C.O.R's License Law far
-00 following moon.(Section 703 I.S.Business and Professions Cale:Any city or county
K m which requires a Permit to consumer.alter,improve,demolish,or repair any structure
poor o its issntrim.also Mquires the applicant for such Permit o file a signs!statement
-Za
hat he is Licensed pursuant to be provisions Of the Contractors License Law Chapter 9 Sq. Ft. Floor Area Valuation -- .
zFo (commencing with Section 7")Of Division 3 of the B usinus and Professions Code)ter
i that M is exempt therefmen and the haste for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects de applicant m a civil penalty of 3 2V'O�R:O 0 Occupancy Type
not roam than Five hundred della.(SSIXq.
I,as owner of the property,in my employees with wages in their role compensation,
will do the work.and the swoon,is not intended or offend for son(So,.71114,Business
and Professions Code:The Conuacwrs License Law dos oil apply m an owner or
- - Required Inspections
property who builds or improves thereon,and who does such work him sel f or through his
ownemployces.provided emlesuch impmvemenuarcnotintended aoRered forsah.If. - _ -
however,In building or improvement is old within one year ofmmpleuon.the owner- - -"
builder will have the burden of proving Nat he did not build or improve for purpose of
.le.).
❑1,as owner of the progeny,am exclusively contracting with licensed explosion to
compact the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense Law dress not apply to an owner of property who Wins or improves thereon,and. -
whomntnctsfor such projects with a comacmr(s)licensed pursuant w the Cornerstones
Liceson Law. - -
I an exempt under Sec. .B d:P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
a 1 hereby arnnn under penalty of perjury one of the following declarations:
1 have and will maintain a Cenificae of Consent to xlf-insure for Worker'sCompcn-
7M37M
tion,as Provided for by Section 3700 of the labor Code.for the perfmmance of the --. - -- -- -
ork for which Ibis permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of the Labor Code.for the performance of the work for which this permit is issued.
My Wo era Compensation maurance gamier and policy number arc:
-n.'' FJPo1Iey o.:
�C FICATE OF FXEMPII_ OcAY 6:M WORKERS'
COMPENSATIONYRSURANCE
mus section need not W completed if the Permit is fusion hundred dollars(SIOM t
or lass.)
1 moify has in the Kofintmauce of the work for which this permit is issued.I shall not
employ any Perron in any manner an in m become subject to the Workers Compensation
Laws or California.Date - -
Applicant - - -- - _
NOTICE TO APPLICANT:If.after making this Cerifinem of Exemption,you should
become subject to the Worker's Comp ussomm provisions of he labor Cndc,you in=
roMwith comply with such provisions or this permit shall W deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
[r.+ Thereby affirm that Jere is a commuction lending agency lot he pcourmanen of
C' he work for which this permit is issued(Sec.3037,Civ.C.)
W Q Lender's Name
=Z Lender's Address
U O I certify hat I have read this application and stain hat the above infmmauon is
W f'^ correct.1 agree to comply with all city and county oNinances and sue laws nothing to
0U building construction.and hereby authodae representatives of his city to enter upon the
r W above-mentioned Property for inspection f urimses.
CL (We)agree to saws,indemnify and one,harmless he City of Cupertino against
f'
Liabilities,judgments.costs and expenses which may in any way accrue against said City
in
his parool-
U ? APPLICANT UNDEof the RSTANDSfmLin@ Of tAND WILL COMPLY WITH AL NON-POINT Issued by: Date
SOURCE ATIONS. !O
Re-roofs
Sin ice A ranUConuactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant store or handle hanrdoua nounnal
as defined by the Cupertino Municipal Code.Chapter 9.12,and he Health and Safety
code.Scetien:ss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the a liaam r forum builJin sr, t rax e t a dew;eca which
If a roof is installed without first obtaining an inspection,I agree to remove -
pp g o non quipmen _
mit ha'rardnes ai onnumman6 the
by the Bay Area Air Quality Management all new materials for inspection.
Distt ct?
QYcs NO
Ihave real him hm susmaterialsrequimmcnuunJcrChapmr695ofthcCalifor-
niallulth&Safety Code, Chun",
and 155341 understand I.,if he Wilding
does not currently have a mnane that it is my responsibility to nod ly the¢cogent of the
requirements;iwwti It prior m mention of Cefor, as of Occup e. tore of Applicant Date
— 1 sego
own rivedagen Dae All roof coverings to be Class "B" or better
s Community Development
�r 10300 Torte Avenue
av Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERM T #
'606b, 40.4" e s-re-L d 2 C, , , ,�o O`� f bC�Ov
OWNER'S NAME: eo e,s /o le-�116, PHONE #
GENERAL CONTRACTOR: Qo,3 FAX # S?o -? 9rSc z
I am not using any subcontractors: O;5
Signature Date
Please check applicable subcontractors and complete the following information:
66 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
T
i to b
Owner/Contractor Signature D to
Community Development Department
Building Division
City of Cupertino
f - 10300 Torre Avenue
9`l �
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPEkTINO
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:
Job Site Address: 2-0,30D 4= v STP 4_d Q C" P,.-i T 6&Jci
Roofing Company Name:
A plicant's Signature: i' Date: % 0 `�
® Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
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CITY OF CUPERTINOR1EROOF C 0
UPEkTINO PERMIT APPLICATION FORM
PKPN Z /
Building Address: IJ
208cn
Owner's Name: J Phone#:
(L✓v�:l'� 2v ' L0PCA7 /lvc. b'50- S`, - SScxo
Contractor: Phone#: `Jeense #:
Contact: 0 Phone #: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles >( Asphalt Shingles
>[r 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.
Have Read, Understand and Will Comply With Cupertino's Tear Off Policy:
ob Description:
Tcc r s3 /NS sae Neal 3o erj aS4ocrkok
Residential ❑ Commercial -ro VV�Tc,(A EX/S'LN� r o0F
Fire Zone: Yes ❑ No ❑ Confirmed with Plarim J cot. if
there are any res . tons: ET
C —itrte_p e of Constructs Occupancy gr
– 7
ADO
Qty. if
A 1 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