05010115 Ip CITY OF CUPEW1'INO
BUILDING DIVISION PERMIT CONTI2AGTOR'ANFORMATION '
BUILDING ADDRESS: DUBOIS ROOFING, INC ""'T
N005010115_
120900 TRAB- R.D # 29
OWNER'S NAME: PERMIT ISSUE DATE
PRnPFRTTFC INC
O.
ONE: SANITARY Nii� CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDC IEL�ECT PLUMB MECH
+00 LICENSED CONTRACT'OR'S DECLARATION Job Des r gI
�S �t tt E l� O
u C I hereby affirm that I am licensed under provisions of Ch
aper 9(commencing I P9 t!
ZU wor ith section]IXllB of Division3of the Business and Profcssiums Code,and my license is M�id7O�'�`4A
t< in full force and effe t. '�
;q License Class �--9Lic.gREROOF W/ASPHALT
o Dae Cior crar
i�� RCIIIT-,,DECLARATION MARS 2005
c1 understand my plans shall be used as public records
U
�up3 LiicnuJ Professional {(1Q p�� !
OWNER-BUILDER DECLARATION IILII=vl//(1'ry'@�tltl11 it Lo I (y,�,�
Y 1 hereby affirm that I am exempt from the Contractor's License Law for the A W;1 `° 1?1
p O following mason.(section)(151.5.Business and Pmfexsions Code:Any city or county C Vd 'Kc.1"
<w which requires a permit in construct,alter,improve,demolish,or repair any structure
prior tons issuonce,alsureyuires the applicant forsuch permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law(Chaplcr 9 Sq.Ft. Floor Area Valuation
eFo (commencing with Section 5(188)of Division S of the B usiness and Profiuinns Cesle)ur
i
that hels exempt uncertain and the beau for to alleged esemption.Any violation of
Section 7051.5 by any applicant for a pmmit subjects the applicant to a civil penalty of 3 2WV54t flbero 0 Occupancy Type
not more than five hundred colla..(S50)).
0 1,As owner of the property,or my employees with wages as their sole compensation,
will do the Work,and the 1Wstom Is not intended or offered for sale(Sec.7044,Business
Add Professions Codi:The Conusmrs Lt..Law does not apply m in owner of Required Inspections
pmperty who builds or improves thereon,and whodoes such work himself or Brought his
awn employees,provided Na such improvements are not intended or offered fortune.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden.(proving that he did nm build or improve fur pro.of
vain).
0 I,as owner of the property,am exclusively contracting with licensed contractors e s
construct the project(Sec 7844,Business and Protection Code:)The Contractor's U.
cense law docs not apply to in owner or progeny who Wilds or improve Nemod,and
who contracts for such projects with a eontnetor(s)licensed Pursuant to the Contractor's
Licese Law.
I am exempt under Sec. ,B&P C for his Mason
Owner Data
WORKERS COMPENSATION DECLARATION
T hereby offirm under penalty of perjury me of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker'sCompen-
nation,As provided for by Section 57W of One Labor Code,for the performance of the
work for which This permit is issued.
1 have and will maintain Worker's Compensation Insurance.as required by Section
W of the labor Codc,four she performance of the work for which this permit is issued
My Worker's Camp ( nIrm Ocm carrier and Policy number am:
Carrier: Policy No,:
CERTIFICATEOMPO E EXEMPTION FAA WORKE0.5'
COMPENSATION INSURANCE
olds action need not bceampletid if de permit is for one hundred dollars(SIMB
to Icss.)
1 certify Nal in the performance of do,work for which this permit is issued.l shall not
employ any person in any manner so As in become subject o the Workers Compensation
Laws of California,Dare
Applicant
NOTICE TO APPLICANT:If.after making this Cenificae of Exemption,you should ,
become subject to the Worker's Compensation provisions of the Labor Code,you must .
�(z forthwith comply with such provisions or this perm it shall hi deemed invoked.
Z CONSTRUCTION LENDING AGENCY
Ihemby affirm that thele iso comtmninn lending agency fnnhe performance of /
1A the work(a,which this permit is issued(Sec.5W7,Co.C.) S
'A Q Lender's Name
z Lender's Address
J 1 certify that 1 haw read this application and site not no Above information is
y F correct.)agree to comply with all city and county ordinances and state laws relating to
�U building construction,and hereby audioriao mpfeatmatives of this city to enter upon the
W above-mentioned property for inspection purposes.
D. (We)agrm on save.indemnify And keep harmers the City of cupcninn against
h Iiabilificapdgmenu.Imisrnd eapcmes which may in Any way accroeagainn said O,y
J z APPL CANf'eof On:UNDERSTANDSranting of Ihis AND permit.
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R}:Gtfl. IONS / Re-roofs _
Signadme afApplicaHAZARDOUS MATERIALS DISCLOSURE are Type of Roof
Will Ne applicant lir future building occupant store or handle loinodons materia)
as dcfineby the CupeMunicipal Code,Chapter 9.13,and the Health and Safety -
Code.s❑Yes ectl lionzss52an ninu All roofs shall be inspected prior to any roofing material being installed.
Will due applican,or mtae wilding«capons ate igiipmenl of devices which -If a roof is installed without first obtaining an.inspection,I agree to remove
it hazardous air contaminants As dcGncd by the Bay Arca Air Quality Management all new materials for inspection.
Wier?
0Yes Nu
Ihawma LhehzvaNnusmawrialsmquimmenuundcr Ghaper6.95ofthc Califor- ,
Idannotermently
building .L� O�haw s rcnanl,Nal it u myrespomihilitybnndlacy the upent of Ne
uiremenu which mum be mel prior to issuance of a Cediocam of Occupancy. . Signature of Applicant Dat
" ° All roof coverings to be Class "B"or better -
Owner lir authorized agent butte
.w., Community Development
10300 Torre Avenue
t { Cupertino CA 95014
7
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
7p800 e --16ST j Q.)) A-;6 OJ 0/ b // S'
OWNER'S NAME: .L PHONE #,:f to 7Y3 ,97 0
GENERAL CONTRACTOR F w FAX # `p ;ze9sz)
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 ate
Community Development Department
Building Division
City of Cupertino
• "` 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEI�TIN®
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 " 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
Job Site Address: 9A13.0
Roofing Company Name:
A eal
plicant's Date:
Greg t
Building Official
Revised 1/30/03
Printed on Recycled Paper
=� CITY OF CUPERTINO
REROOF oho ° t
UPERTINO PERMIT APPLICATION FORM
N# 6 0
Date:
Building Address: S Zq
20 Sm
Owner's Name: Phone#:
(p✓tn�.0 �Q t1 / Y e-/1 b o- S ) S �CY>
Contractor: Phone#: icense #:
Contact: Phone#: Cupertino Business License #:
C1�l/tZl� ���joty Slo �I� �BO�I
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 O 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 Polic
ob Description:
i eNr oFf -71)1, 053 tied 3o eev as4oarkooe
Residential ❑ Commercial
Fire Zone: Yes ❑ No ❑ Confirmed with Planni e t. if
there are any res . tons:
Co o� e of Constructs Occupancy gr
DEC
Qty. if
A 1 abe 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