05010113 CITY OF CUPERTINO
BUILDING DIVISION PERMIT s CONTRAC1 R'INFTO.RMATI,®N .
BU I I.DING ADDRESS: DUBOIS ROOFING INC PERMIT NO,U 5010113
Ann NnMT?.qTFADRD 2G
OW NER'S NAME: PERMIT ISSUE DATE
- -PROMETHEUS PROPERTIES , TN(- 99 DITAR 17. ANTE n1 /20Z200c;
ONE: SANITARY NO. CONTROL NO.
(510 19 -
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
Idd, LICENSED CONTRACTOR'S DECLARATION Job Description
w 1 Wmby affirm Thal I am licensed und......isions oIf Chapter 9(commencing p
ection 70(111)of Division 3 of the Business and Professions Code,and my license is
<� with Sidfull mmeand ef c Z3o . REROOF W/ASPHALT SHINGLES ' rgII�� ////!���� ttI{tj��y
Z Dole Clrss_ �_Lk,X Its IN� td
5Fo Date II�>n rl+er..+ ��CSDECL flttll�r e&
qqW / r AB11111BCT$DECLd ATION
fC R 1 understand my plans shall W used as public records
76p
ELiccnudPmfcssidnel
OWNER-BUILDER DECLARATION MAR 23 2005
1 hereby affirm that 1 oto exempt from she Commaor's Liecnu Law for the
n following mason.(Section 7(A 1.5,Business and Professions Code:Any city err county �eet�,
which requires a permit to emostrucL alter, sum � '(3
improve,demolish,or repair any atrucr7
prior lu its issuance,also requires the applicant for such permit m file a signed stammerer
"cSathat he ishecmind drsusmbthe provisionsofthe Contractor's LicenmLaw(Chapter 9 Sq. Ft. Floor Area U Usess BeassV61datildn"alsov
yFG (cumme ring with Section 70(k)of Division 3 of the B clowns and Prufeuions Code)or
$ that he is exempt thcrtrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjcm the applicant so a civil penalty of 32AOIDNOOCC00 Occupancy Type
not more than five hundred dollars(5500).
❑I,u owner of the pony.or my employees with wages ax thou in compensation.
will do the work,and the structure is not intended or offered for sale(Sec.)OSA,Business
and Promsxions Code:The Contractor's License Law dos not apply to an owner of Required Inspections
property who builds or improves chefeen,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however.the building Or improvement is sold within one year,of completion,the owner,
builder will have the burden of proving that be,did not Wild or improve for purpose of
salt.).
❑h as Owner of che ymRny,am exclusively contracting with licensed commuters to
consumer the project(Sec.7064,Business and Professions Code:)The Con racwrs Li-
se law docs not apply to an owner of property who Wilds or improves thcroan.and
who contracts[of such projects with a con racter(s)licensed pursuant m the Contractors
License Law.
❑ I am exempt under Sec. .B&PC for this mason
Owren Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aMo.under penalty of perjury ore or Be following declaration:
1 have and will maintain a Certificate Of Conscnuo self-insure for Worker'sCompen-
satma,az provided for by Section 3700 of the labor Code.for the performance of the
we, mwhichthispermitisissucd.
I have and will maintain Worker's Compensation Insurance,az required by Section
3700 of chs tabor Cos .for the pcffonnanee of the work for which this permit is Wood.
My Work s}Compuuatia/n`lnsunnym easier and Policy number aam': _
/—}la Carrier: .G�. =l 1-t�YL3. Polmy No.:7��1
CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section decd nm W completed it on permil is foronc hundred dollars(510.7)
or lesx.) ,
I cenifv that in the performance of the work for which this permit is issued,I shall not
employ any parson in any manner so as w Weomc sooner to the Workcri Compensation
Laws of C.Rmmia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shouW
Wcome subject m the Worker's Compnwtion provision.M the labor end.,you most
=O forthwith comply with such provisions or this permit shall se deemed mvnked.
y CONSTRUCTION LENDING AGENCY
I hereby a1Erm chat there is a construction lending agency for the perfurmancc of
:4 UC work for which this permit is issued(Sec.3097,Co,C.)
]] Q lender's Name
1 Unders Address
2
J Q 1 .nify Bar 1 have read this application and sate Bar the above information is
y, F correct.I agree to comply with all City and county oNinances and some laws relating to
V hb.,.-gcotiound mgand hereby author..me.roemativcs of this cnymcmcr upon the
W anove-(WO)ag agree
save for inspection keep x.
(WO)ague to save,indemnify and keep handless thew City of Cupertino aagainst
r Z incomeoBsunce oft a grassing espcasmwhich mryin any way attmc against uid City LD O (_
J 'z A ePLICAN ce ND granting of this D WILL
1 J
^ APPLICANT UNOE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE RE N`�V A L /
�-(Q �� Re-roofs
Sig2rc of ApplicauVCOntracwr Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ftrwrc building occupant smre or handle h.,xmI material
az defined by Etc Cupertino Municipal Cole.Chapter 9.1Z and the Health and Safety
Cole.Snodi.o 15533(x)? All roofs shall be inspected prior to any roofing material being installed.
Will Be applicant or fuwrc building om:upam vu cyvipmem or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove .
It havaNmis air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
ialrict7
( Yea
I have mad the hmardus materials requirements under Chap¢r 695 of the Califor-
nia
alifor-
lh&SefeySections fW3553A.l unhnondWilding
doesOut currently have.Worm,chat it is my onxponsihiliy w notify She..,am or the
ohulmmcno - ustWmelpnormBud...r.certifca¢o cupadp Signature of Applicant D to
—i b5
Owner or amhormed agent Date -AIL roof coverings to be Class "B" or better
a Community Development
' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: . PERMIT #
r 24 .0��/b �/ 3
OWNER'S N : r ✓o�t� a PHONE # - Ej 7,6
GENERAL CONTRACTOR: /,6 FAX # S 6
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
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 6ae
Community Development Department
F, Building Division
City of Cupertino
{ °T 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: I,uc
!// e
Job Site Address: 2-050o G6 S%ez-�
Roofing Company Name: -bC1g0J5 (2V0J(1`-Uy
Applicant's'ignature Date: / S'
it 'A
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
UPCITYEIZTINO PERMIT APPLICATION FORM 3
'RPAPN# 3 2G OS-6 Date:: 7 0
C� r� �
BuildingA++ddress:
ZOU oM � pP/1 /NC I S� Li C- S 3�
Owner's Name: Phone#:
✓ .('� 2v ' ;urea— //u c. k/,o- 5li
Contractor: (( Phone#: J license #7: V
0) J_ 9'.7 V O r I L 3 b l
Contact: Phone#: Cupertino Business License #:
SIo -IVA - , 1Soc(
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
?a, Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings I ❑ Provide I.C.B.O.Report#
J To be Removed ❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
ob Description:
—Ia4 OFF E�rsT�+ 51 Ales „�srq u ew 7 /6" os3 /Ns,-a ( NeW 30 Y6AJ aSf"CI" 00f
Residential ❑ Commercial -r'o E)4/S'A
Fire Zone: Yes ❑ No ❑ Confirmed with Planni e t. if
there are any res • tons:
Co e of Construct r Occupancy 9 7
Qty. if
A l ab 61 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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