04100008 CITY OF CUPERTINO � 'q�'E' " `t' bb '" •" - -- 1
BUILDING DIVISION PERMIT CONTRACTORANFORMATION
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ILDING ADDRESS: DUBOIS ROOFING INC PFR
MIrN 04100008
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OWNER'S NAME: PERMIT L'SUE DATE
ONE:
SANITARY C ftO,NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
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Sara LI CENSEDCONTRACTOR'S DECLARATION -Ipb Description -
Un I Mmby firm shall am liarued uaJgEyrovisiom of Clupmr Y(commencing _
iza`$ wish Savo )of Division 3Ofdu Bu4 and Pmfessinm Code.andmylicense is -
infullfo dcfrttLn - - - - -- s
jZ,Z Liccnx Chas ` 39 Lic.g 1 Z` ILK REROOF W/ASPHALT
nE'mw Dam ,� T��yARCH CTSDECLk r C
7 IundLt my Jas crob
-
;0G Licensed Professiaal
S OW NEm O.Op.DER mDECLARATION
+� 1 hereby.. affirm on 1 1. exempt from Ne earths Co License Law for Ile
i'0 following lesson. etch t ](1315.Business and tie. Tum demolish.of Any An nr county -
,C m which myuims a pmmit re uirssrue alms Improe, erittri repair ed umment
u-w
prior mits censed e.pursuant
nt to
he thovisio antsot for such Contractor m0erisle ac Law(chapter
_
-i<
that
commencingwJourstion7C)ofDivioasn oftheB sinessanimnxLaw(Chaper9 Sq.F[. Floor Area _ Valu tton _
yFQ (Cor he is
Section Division3 us sheeged excerptioand n.
Any ns volmho)of .
that he u esemps themfram and the basis for the alleged essmption.Any vialeuon Of
Section 7031.5 by any applicant for A Permit subjects the Applicant o a Civil penalty of 3 2 'bLT#`CN 0 Occupancy Type
not mom than fir,;hundred dollars(5500).
❑1.as owner of be proputy,m my employees with wages as Heir Salo compensation,
will do the walk.and the structure is not intended.0coul forage(Se..7044,Business
and Pmressiom Code:The Conaacmra Li.Law docs not apply m m owner Of Required Inspections
pmpeny who builds orimprnves therron,and who does suchwork himself orthrough his -
manemployrrs,provided Nm such improvements arc not intended oro@md for Sale.If.
however,the building or improvement is Sold within can year of completion,the rwner-
builder ,will have the burden of pmving that he did not build or improve for purpose of ,
Sale.).
O I,as Owner of the portion,am exclusively Contracting with licensed contractors to
consumer the pmjem(Sec.7044,Business and Pmfeesions Cade:)The Contractors Li
cense law docs nos apply m an owner of property who builds m improres thcmon,and
who eonsness for such projects with a eontrAetor(s)licensed pursuant to She Contractors
Lkenx Law. -
1 Am exempt under Sec. .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION -
1 hereby affirm under penalty of perjury ane of the following declarations:
I hate and will maintain a Ccrvficmu or Consent mxlf--insum for WorkceaCompen-
7031�]
non.AS provided for by Session 39W of Ne IoW,Code,for the perfon"ana of the ------ -
rk for which this permit is issued.
1 ban and will maintain Workers Compensation Insurance,as required by Section -
of the labor CWc,for the performance of Ne work for which this permit is issued.
WW/Worrker's CnmpenauioInaun acarrier andP number Amue ST4TP Y✓sal U\ -3.2 -0
/ CERTIFICATE OF EXEM MON FR0M WORKERS'
COMPENSATION INSURANCE -
(phis Aad.need not becomplemd ifthe permit is foronc hundred dollars($100) -
or Less.)
1 cenify that in the performance of she work for which this permit is issued.I shall not
employ any person in any manner so as m become subject to the Workers'Conorkmation
Laws of California.Dave -- -
Applicant -
NOTICE TO APPLICANT:IL after making Of.Ccnifium of Escmplion,you should
become subject to he Worker's Compensation provisions of me Labor Code,you most
.JO forthwith comply with such provisions or this permit shall ba deemed revokcd.
Z H CONSTRUCTION LENDING AGENCY
'fes. Ihem6y affirm
that there is a construction lending agency for she performance of -
DC 7 the work for which this permit is issued(Sec.3197,Civ.C.)
!y lsndcr's Name
n' Lender's Add..
VQ 1 cenify that l have mad this application and stem Nu the dbose infamauun IS .
L, F-' COMCL I agree to comply wish all city and county oNinances and sou laws rtlaung to
0 building construction.And hereby authann,represcnutiws of his City m enter tion"um
>+ G above-mentioned property for irupecuon purposes.
(We)Agra to Save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City I//_
U in consequence of Ne granting of this permit. I/
APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGULA
%may Re-roofs
Si A ianUContrantor IDalc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle havardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
AWL",Section 255320)? /' All roofs shall be inspected prior to any roofing material being installed.
�Y ceNa
Will IM applicant o felere bedding Occupant ux equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7mquiremer,
mit ha'rasdnus air contaminants as defined by Jm Bay Area Air Quality Management all new materials for inspection.
isnic'
❑Yrs No
than mail the haaa "us materials requirements under Chapter 6.95ofthe Califor- /♦
iaHeallh&Safuy CWC, LUOns MS.25533 and 25534,1 understand that ifdu Wilding
ors not comencty ban a¢nano that it is my responsibility to nod ly doe aeupane of Ne
sat IA:mel pnaf IU i5stid11CC Of d CCIIIfICom Of CUpanLy. T
Signature of Applicant Date
narnt Anchorirc agent Dam - All roof coverings to be Class"B"or better
- Community Development
RAM
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building Department
JOB ADDR SS: V1„n� PERMIT
/J �j�( b000 8
OWNER'S NAME: I fvNtiVl PHONE # G$ S= --
GENERAL CONTRACTOR: FAX # 5;e y 9f Z
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
M1 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
AUPEkTINO
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! o /21 LA' 1roPe` tC-S /^^tiC
Job Site Address: ZC)$D()
Roofing Company Name: 1Jujyo;S �r ^' TIAJ
A plicant's Signature: T .0 i'� Date:*0
1/
Greg teel
Building Official
Revised 1/30/03
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CITY OF CUPERTINO
RE ROOF
UPERTINO PERMIT APPLICATION FORM
Date:
N# 32-6 e S-6
BuildingAddress: �1 Z
20 o T C�Pzn —�n,� r, ( « SS a cL 'S
Owner's Name: Phone#:
Po✓,.� .:C�,�,v � - (uPP.�— //ucb5o- S `Ib S �cx,
Contractor: Phone#: r,icense #:
INC SQ_ y
Contact: Phone#: Cupertino Business License#:
tl/11F21� P�o� S 5jo 1►`1 - X180`1
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 I ❑ Provide I.C.B.O.Report#
1 To be Removed ❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
1IFob Description:
-leos of EAST tJ 5 os3 "eW 3vew ase c of
Residential ❑ Commercial —fes Nn TGtA EXiS;T)i J r zoF .
Fire Zone: Yes ❑ No ❑ Confirmed with Planni e t. if
there are any res tons:
Cor p , o,� e of Construct] Occupancy gr 9
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
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