05010114 • CITY OF CUPERTINO E' s 4' r"xi •'r '» " ck ?`: ..
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
Bu 11AING ADDRESS: DUBOIS ROOFING INC PERMITNQ5010114
Ann HOMESTEAD RD 4 29
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION'
Wp I hereby affirm mal 1 am emmacd ander pervidons of Chapter 9(commencing Job Description
� W wilM1Senion]O(Ngof Divisian3of the Btminczand Professions Code,and mylicenu isse
� � �p
in, Im..and fir t ii3`Sm
;'qi Licen el9 39 Lies lZ3v 1 _ J'EROOF W/ASPHALT, .
=Fp Dam f/zeTs� Con DEC I
['pp','J , ARCHfTELTS DEC A ION
C of-a I understand my plans Aall ne used as puhlic amoods
MAR L2U0 5
�x.t; Licensed Professional
3 OWNER-BUILDER DECLARATION
<y I hereby affirm that 1 am exempt[rum the Codmato's License Law for the E
p o following music..(Section 703 1.5,Business and Prtfc.caimn Code:Any city or county l
<w F which mquires a permit to construct,alter,improve,demuliah,or repair any suoetum
r prior to its issuance,almosquims the applicant forsuch permiuo file a signed statement
-i< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 .. Sq. Ft. Floor Area Valuation -
dFp (commencing with Section 7")of Division 3 of the Business and Professions Crater or
_ Nal he is exempt Iherefrum and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pearan subjects the applicant o a civil penalty of 3 2A00V9t5ecr0 0 Occupancy Type
not more than five hundred dollars(9500).
1,as owner of Ne pmpcny,or my employcas with wages as their sole campcnsstion,
will do the work and the swnum is not intended or offered for sale(Sec.7W,Business
and Professions Code:The Conaaclors Liave Law aures not apply to an owner of Required Inspections
propeny who builds or improves thereon,and who does such work himselfor through his J 1
own employees,provided that such improvements are not intended or offered formic,If.. J .
however,the building or improvement is sold within one you of completion,the owner
builder will have the burden of proving that he did Out build or improve for purpose of
sale.).
❑ 1.as owner of the property,am exclusively contracting with licensed conaanora to
conserver the project(Sec.]Oma,Business and Professions Code:)The Contractor's Li.
cease law does not apply to an owner of propeny who Wilds or improves Ihemon,and
who contracts for such projects wit a convectors)licensed pursuant to the Contractors
License Law.
1 am exempt under Sec. .B h P C for this mason
Own Dale
WORKER'S COMPENSATION DECLARATION
I hereby Non ocular pointy of perjury our of the following declarations:
I have and will maimsem self
nodular a Cenifcem of Connt -insure for Worker's Cumcm
p
sation,as provided for by Section 37W of the labor Code,far the performance of the
wink for which Iris .it is issued.
have and will maintain Workers Compensation Insurance,az m luired by Section
TOO of me labor Code.for the performance of the work for which this Permit is issued.
My Warkora Cnmpensa(1�inn lin ynce eemier and Policy huunker art'
Cartier: S7' ,P I t/N[( Policy No.: -5
CERTIFICATE OF EK EM MON FROM WORKERS'
COMPENSATION INSURANCE -
mos xetitm aced nal W completed if the permit is fm one hundred dollars($100)
or less.) ,
I cenify that in the performance of the work for which this Permit is issued.1 shall not
employ any permn in any manner m Or to hecome subject to the Worhmi Compensation
Laws of Celifomia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenilicale of Exemption,you should
become subject to the Workers Compcauation provisions of the Labor Code.you must
z foMwi lh comply with such provisinm or this Permit hall the deemed revoked.
z CONSTRUCTION LENDING AGENCY
.I hereby affirm Nat them is a construction Icndi n6 agency for the permrmantc of
x he work for which this permit is issued(Set.3097,Civ,C.)
:fid Q Lender's Name
1 Undeis Address
� z
O I cenify that I have mad this application and sate that the move information Is -
y (~ wren.I agree to comply herr all city and county ordinances and stain laws relating to
e
building eotioned morand herrot inspection
ns eumon p representatives of this city to enter upon the
= V
above-mentioned,m properly far emnify an purposes. T
(We)acme to cove,indemnify end keep harmless the City of wCupcnst against / +
rex Iimoscm,judm of thocommand expenses;which they in any way aecme against mid City
;Jz Aconsequence of DERSTNU[this per mit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PONTIssued by: Date
SOURCE Rf;G9LAT10NS. ^ _/O
`/%// 1fh" Re-roofs
Signature of ApplicanUCantncmr D
HAZARDOUS MATERIALS DISCLOSU RE Type of Roof
Will the applicant or future building occupant store or handle havaNuus material
as defined ny the CUDenino Municipal Code.Chapter 9.12,and the Health and Safety
Codc,Scclion25532(ar? All roofs shall be inspected prior to any roofing material being installed.
❑Yas
Will the applicant or future building«capent axe equipment.1devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it ha'rardous air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
1!�_,
0Yes X'u
Ihaveread Codc.She Nausmamrialamquimmc55u.I rChapter deman6.95ofe,Wilding Hoards& ntlyhave.lecruam 25505.25533and2553a.lundersande omop Wildingcs not curtently have a mnmt,Ia it is my rnpoaminiliq w nntity the acupanl of meairemcnLy; a` e=primmi:maaneenracen;reamorcap-e.s Signature of Applicant D e
Owner or authorived agent / Date All roof coverings to be Class "B"or better
Community Development
^ c 10300 Torre Avenue' ' / Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
OUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
70800 o t'^-eST2wB .o>
OWNER'S NAME: �vP�riF HONE # 1lo 76a
GENERAL CONTRACTOR: FAX # /a7f3 SSS
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
A
Owner/Contractor Signature Dat
Community Development Department
�t Building Division
City of Cupertino
�.
10300 Torre Avenue
Telephone: (408)777-3228
CITY Of Fax: (408)777-3333
UPEIT INO
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:
Roofing Company Name:
A plicant's Signature, Date:
\.N'�LODCXt
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOFOF
PEkT
CUINO PERMIT APPLICATION FORM
MN# Date:
Building Address: S
2060
Owner's Name: Phone#:
(�✓tie.C� PL1 (cYP1 /WL >JSG- S`-1 S OU
Contractor: r Phone#: r,icense #:
Contact: Phone#: Cupertino Business License#:
Sto -I - 8 0(�
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles jit(' Asphalt Shingles
°X' Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings 1 ❑ Provide I.C.B.O. Report#
To be Removed ❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
ob Description:
Tear oFF ��rsT 51,pl�es ,>,s,-s] u os3 RNs%au /veW so ew aSAA cT voF
Residential ❑ Commercial To 1M�Tt� EX S'f vr� C GJF
Fire Zone: Yes ❑ No ❑ Confirmed with Planni e t. if
there are any res sons:
Cc ! e of Constructs Occupancy gr 7
ou
Qty. if
App 1• ab e I 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