03070030 n CITY OF CUPERTINO 'y'i° M 1,
BUILDING DIVISION
PERMIT CONTRACTnR INE , RMA'�ION
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BUILDING ADDRESS: PERMIT NO03070030
OW NER'S NAME: PERMIT ISSUE DATE
JNE: SANITARY N0. CONTROL Na
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i00 LICENSED CONTRACTOR'S DECLARATION
w p 1 hereby affirm that 1 am livened under provisions of Chapter 9(commencing 1i�ED
O with Section 7M))of Division Jud the Hnnncslind Professions Cnde,and my lieenu is
n. mmnmmctudcffuL REROOF
License Class Lie.a JAN 1
= o Dam Contractor 2 2004
ARCHITECTS DECLARATION
e < I understand my plans shall he used as public records
'A.0 D BUILDING
a Licensed Professional .,
3 Bar I am exempt fr DECLARATION
I hereby al Grm op I em exempt from the Contractor's Co e:Any c Law for the
p o following reason.(Section]OID.S,Business and Professions Code:Any city nr county
<$Fa which myufms n e.alau re erect.AhCr.improve.demolish,ri repair any strecmre
u—m poor that he iBismedro .andI.do,res the
oviionOfforsuch C.Otorm's o rile Liec .LawJeatomem
'fin that incingwJpursuanuothepmvismiu 3ofthe rosiness ndProflaw(sCode)r9 Sq. Ft. Floor Arca Valuation
eFG (commencing with Scnion](gID)ol Division)nfthc Business and Professions Codeor
)
y 3$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 37510005 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to.civil pcnahy of APN Number Occupancy Type
not more than five hundred dollars($500).
t]1,u owner Of the property,or my employees with wages or Nair sole compensation,
will do the work,and Ne structure is not intended or offered for sale(Sec.7W.Business — R
anrod Professiom Code:The Contractors Lt..Law dors not apply to m Owner Or 307 - INSULATegO rgd Inspections
pperrtywhobuilds or improves thercon,and who doessuch work himselforthrough his 1 N
Own employees.Provided that such improvements are not intended or offered for sale.If.. 601 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion,the owner-
baaderwill ban the burden ofproving tat hedid not Wild or improve for purpose of 602 - ROOF PLYWOOD NAIL
71.
603 - ROOF BATTENS
as owner of the property,am exclusively contracting with licensed contnnors to
cotuwn the project(Sec.]OSd,Basin.and Professiom Cee)The Contractors u. 604 — ROOF IN-PROGRESS
cense l*WOREKER—SCOMPENSATION
ply m an owner or property who Wilds or improves demon.snd,
who coprojecsa with a commcter(s)licamsed pursuant to the Contractor's
Lkc
❑luSac. ,Bh PCfmddxeason
DwnerDoor
ep 3 0
' N DECLARATION
under Penalty ofperjury one ofthe following declarations:
1 hast and will maintain a Certificate of Consent to self-insum for Workers Compere
sation,as provided for by Section 3700 of the labor Code.for the performance of the
work for which this Pcrmit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3]00 of Use tabor Code.for Ne performance or the work for which this permit is issued.
My Workers Compensation Insurantt carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnin woucti need nm hecomp cisd if the permit is fm one hundred dollars lilfi(p
or It..)
1 ccnify that in the Performance Of the work for which this permit is issued.I shall not
employ any person in any'mannerso as Nr become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to the worker a Com osseadon provisions of the Labor Codc,you must
.J,'Z forthwith comply with such provisions or this permit shall he deemed mvoked.
zO CONSTRUCTION LENDING AGENCY
P(Z) Ihereby affirm that there is contraction lending agenry(or the,performance of
CL7 the work for which this posit is issued(Sec.3097,Civ.C.)
W Q L emko:1 Namc
a. Under Add.
V O 1 ccnify that I haw read this application and suite that the above information is
W fes' correct.l agree to comply with all city and county ordinances and state laws misting to
0U building construction.and hereby authorim represent,diver of this Ci Ly to enter upon the
OW. above-mentioned pmperty for inspemth purposes
>1 (We)agree to save,indemnify and keep harmless the City of Cupertino against
Q,, llnbuiaeaju mcox-costs aodexpcnes which may in anyway so,. gr inll said City
t.)Z in cony cahh mining of this Permit.
.. APP UN RSfANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 R GU IONS
Re-roofs
Si at an Cotnracto Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
W Itha applicant or future building Occupant store or handle harkimmis material
as(caned by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
Code,Section 15532(x)? 1��,/�;� All roofs shall be inspected prior to any roofing material being installed.
❑Y \
Will the applicant or(wore building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as dchncd by the Bay Area At:Quality Management all new m erials for inspection.
inrlct?
p Yes �No
I have read the hamolnuuss materialsrcyuircmcnu under Chapter6.950(Ne Califor.
Oa Hcal KS ty Ca ,. 'u=25505.25533ud2553E.lundcrsmndtlmsiflMFuilding 3�U
dt•• tly have a totmnt,that it is my responsibility m notify the meupam of the
qui w c Mmet prior toissutMcofaComficamofoocUpanc. Of ant Date
p
tuner r horincJsgrn, Date All roof coverings to be Class "B" or better
I Community Development Department
Building Division
dt,
el City of Cupertino
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 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: -Y n �Ira � Gl D,�Q CGt V^ , ON, t�1 Q,V'
Job Site Address: I O 37 "
V � A-y e-- 1 �'6
Roofing Company Name: S O n
A plicant's Signature: - - Date: 3 r 03
• Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
1
CITY OF CUPERTINO
REROOF o 3 v 7o v; o
OF
CUPERTINO PERMIT APPLICATION FORM
APN# 3 7—r ' ate: 7 (-3 ( 03
Building Address:
103-7 u -IkJe-
Owner's Name: Phone#:
I�a,V_o.vv\, av\C4 w",0\_ (:::j2v S 5/0 . 2S 4F�-/
Contractor: Phone#: License#:
S 42 C4 V 510 - 2 - f9(
Contact: Phone #: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 1K,Asphalt Shingles
__Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ 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: 1�
T—�
Residential � Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project ^ O Type of Construction: Occupancy group:
Qty. if
Applicable 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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