03090042 CUPERTINO
GDIVISLON PERMIT ICON;TRACTORANFORMATION
Bull , GADDRESS: COSMOS ROOFING PERMITNo03090042
T. 423 JTQ141SON AVE
IR'S NAME: 1901 OLD MIDDLEFIELD .WY PERMIT ISSUE DATE
PHONE: (415) 493-6373 SANITARY O. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� Q 0
100 LICENSED CONTRACT'OR'S DECLARATION
<w F I hereby affirm In.,I am licensed under provisions of Chapter 9(commencing Job Description
SZ. with Section 70(k))of Division 3 of the Business and Professions Code.and my license is
in full force an f
)'Ai Liccn.0 a�/`�J' Lien 185 ( 41 ! RE—ROOF/TAR & GRAVEL FINALE®
y a Dale Contractor
f 'y ARCHITECTS DECLARATION
u I understand my plans shall he used as public records SEP 1 0 2003
.o t; Licensed Pmfeasimol
5 OWNER-BUILDER DECLARATION BUILDING i<f 1 hereby affirm that 1 rare exempt from the Comranors Liccnm Law for the WILDING
n o following reason.(Section 7031.5,Business and Professions Cods:Any city or county
`<m 0� which requires a permit to convect,alter,improve,demolish,or repair any structure
°iy prior in its issuance,also requires the applicant for such permit to file a signed indictment
that he is licensed pursuant o she provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuat on
dam$ (commencing with Section 7000)o(Division 3 of the B usiness and Professions Cade)or
- that he is exempt th.mfrom and the basis for the alleged exemption.Any violation of
Section 7931.5 by am applicant for a permit subjects the applicant to a Civil penalty of ane.APN Number OCCU-Type
not more than five hundred dollars(16500). - - -- - p y
❑I.as owner of the property,or my employees with wages az their sol.compensation,
will do the work,and the swmvm is not intended or offered rot sole(sec.7061.Business 305 - FRAME
and Professions Code:The Contncmr's License Law docs not apply to an owner of Required Inspections
property who builds or improves Hereon,and who doessuch work himaelfor through his 307 — INSULATION
Own employ=,provided teal such improvements am not intended or offered for sat..11. 601 — ROOF TEAR OFF
bow wr.the building or improvcne mesn is sold within oyear of completion,the owner
builder will haw the burden of proving that he did not Wild or improve for purpoac of
602 - ROOF PLYWOOD NAIL
a1cJ.
❑I,as owner of the prop.ny,am exclusively connecting with licensed contractors to 603 — ROOF BATTENS
conswn the project fSec.70ed,Business and Poefessiom Code:)The Contractor's Li 604 - ROOF IN—PROGRESS
cense law docs not apply in an owner or progeny who Wilds or improve themon,and
who contacts for such projects with a contractor(s)licensed pursuant to the Contractor's
License law.
❑ 1 am exempt under Sec. B&P C for this mazon _
Date
WORKER'S COMPENSATIONDECLARATION "-
"-
IWrcbyaffumunderpenaltyorperjuryoneofthe following declarations:
❑I have and will maintain a Cenificam of Consent to selftinsum for Worker's Compere '
salion,At provided for by Section 37W of the labor Code,for the perfomtance of the -
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as mquimd by Section
700 of the labor Code,for the perm
forance issued..
of the work for which this permit is
My Workers perwt-io7n I..mm canter and Policy number am:
timer: 'l L
FOR,No. 02-A I TMs
W
CERTIFICATE OF EX EM MON MOM WORK ERS'
COMPENSATION INSURANCE
(This section need not be cmnplemd if rte permit is for one hundred dollars(SIM)
n bent)
I cendy Nat in the perfoonsnec of the work for which this permit is issued.l shell not
employ any person in any manner M az hr become subject to the Workers Compensation
laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CeniOca a of Exemption,you should
become subject to the Worker's Compcmation provisions of Out labor Code.you must
Oforthwith comply with such provisions or this perm it shall W deemed mvoked.
Z h CONSTRUCTION LENDING AGENCY
1 hereby aRrm char them it a construction lending agcnem
y for the perfurance of
th
Y e work fur which this permit is;uvea(Sec.3097.Civ.C.)
1AIsnder's Name
Z) Z Lender:Address
J Q 1 Lenify that 1 have read this application and sum that the shove information is
y Pcorrect I ogre to comply with all city and county UNinansma and sate laws relating w
JU building convection,and hereby amhonm representatives of this city to enter upon Ne
W above-menlioncd property rot insemion purposes.
(We)agree in save,indemnify and keep humless the City or Cupertino against
y
liabilities.judgments.costs and expenses which may in any way accrue against mid City
J Z in consequence of the granting of this perm;L
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT Issued by: Dale
SOURCEREGU NS
�ff )_ 9 /�?
7
signatureofAppbRe-roofs
aH ZARDDUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding Occupant store or handle hanam ous material
At defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
'e.Section 25532(a)?
❑Ye &K� All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building«cu ant uaa equipment If a roof is installed without firs[obtaining an inspection,I agree to remove
rap s v q it Qu or Marta which g p
Cold District' nus air contaminants az defined by the Bay Arca Air Quality Management all now materials for inspection.
District?
❑Yes u
Ihave&Sdcl the Wnrthma 255O5,2553als 3udMSmicams, oder Chap ffimifthe Wilding
n;estaA mo Safetyhaven cetimu 25X15,25533snd2553s.lundoalyich cup Wilding
does not cuts whit haw a tenant,that it is y mspmnsihility to nndly the recupant of the GCJ
mquiremenu whir.hest et priorw ec tufa Cenifc"'of Qcup ry. _
�TsJ Signature of Applicant Date
owner or authbH cd agent / Date A roof coverings to be Class"B"or better
Community Development Department
Building Division
City of Cupertino
• y 10300 Torre Avenue
CITY Of Telephone: (408)777-3228
Fax: (408)777-3333
CUPEQ 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: a /t(�t VD G ..
Job Site Address: 0 L{ 3
Roofing Company Name:
AP'
icanYs Signature: _ Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 37518047.00
DATE ISSUED. . . . . . . : 09/04/2003
RECEIPT #. . . . . . . . . : 23033
REFERENCE ID # . . . : 03090042
SITE ADDRESS . . . . . : 10433 JOHNSON AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GARY BARRY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BONITA JENKINS
CONTRACTOR . . . . . . . : COSMOS, RICHARD LIC # 18844
COMPANY COSMOS ROOFING
ADDRESS . . . . . . . . . . : 1901 OLD MIDDLEFIELD WY
CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94043
• TELEPHONE . . . . . . . . : (415) 493-6373
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 6, 000.00 117.00 0.00 117.00 0.00
BSEISMICRE VALUATION 6, 000.00 0.60 0.00 0.60 0.00
__________ __________ __________ ----------
TOTAL PERMIT 117.60 0.00 117.60 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ __-_______________
OTHER 117.60 VISA
TOTAL RECEIPT 117.60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
REROOF
• CUPEI�TINO PERMIT APPLICATION FORM X30900
APN# 3 f m Q Date:
�j 3
Building Addre s:
Io 3
Owner's Name 16 Phone#:
(-� 3 3
Contracto Ph ne#: License#:
6Sv 01 -7GG.3 ) 85Vw/
Contact: Phone# Cupertino Business Li ense#:
�_ �1
Type of Roof Covering:
Exis 'ng: Proposed:
I
Built-Up RoofBuilt-Up roof
ElAsphalt Shingles ❑ Asphalt Shingles
❑ 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.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description;70
Residential Commercial
Fire Zone: Yes ❑ No ❑ Confirmed with P rang e t. if
—� there are an tri tions:
Cost of Project: Type of Construct o Occupancy rou
S�250 . [TD
ty. i
A licab e Fee ID Fee Descri tion Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energv BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING