03070031 CI'T'Y OF CUPERTINO 1 : tiv
BUILDING]DIVISION PERMIT CONTRACTOR+INFORMATION �'
BUILDING ADDRESS: PERMIT NO.03070031 3070031
OWNER'S NAME: PERMIT LSUE DATE
NE: SANITARY NO. - CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X0w 0 LICENSED CONTRACTOR'S DECLARATION lob Descriptton
1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing� 11'�� with SectionThrap.f Division 30ftw Bositcaand Pmfcuium Cock.and my licephe is e p
s
in mB Tome and edea. REROOF "`/� �
Z_ U.M.Clue Lie.g
'Fn Date Contractor
H ARCHITECTS DECLARATION
UI understand my plans shall be used as puhlic records UL 2 5 2003
su. Licensed Proe,sitnal
uOn
OWNER-BUILDER DECLARATION �LD1��
L<q 1 hereby affirm that I am eacmpt from me COnaaneri,License Law for the
OO O following reason.(Section?031.5.Business and Professions Code:Any city m county
V
5 m which requires a permit to construct,alter,improve,demolish,or repair any structum
_It adorns its issuance.also myuimube applicant for such permiuu BlcasigncJ sutomcm
Eco that M is licensed pursuant in the provisions of the Contractor i License Law(Chapter 9 Sq. Ft. Floor Area Valuation
mv- (eons meneing with Section?000)of Division 3 of the Business and Professions Codgor
i $ Nat he is esempt themfmm and the basis for the alleged exemption.Any violation of 3 7510004 . 00
Section 7031.5 by airy applicator fou a permit subjects t1
the applicant a civil Penalty of APN Number
not room Mo.five hundred dollars aSW). Occupancy Type
❑ 1,M Owner of the PrOpeny.Or my employees with wages m their sole Compensation,
will do the work.and the svnclum is not intended or offered for sale(Sec.IOW,Business
and Pmfcssiom Cade:TIM,Contractor's License law dors not apply to an owns,of Re uired Inspections
prorany who builds or improves themon,and who does such work himselfor through his 307 - INSULATYON
awn employees,pmvidcd that such improvements are not intended or offered forsale.If. 601 — ROOF TEAR OFF
however.Ne building or improvement is within ane year of completion,the owner.
badderwill ban thehurdenofpanning wtwdmnot Wild orimprove for purameof 602 - ROOF PLYWOOD NAIL
sale
1,as owner of to property,am exclusively contracting with licensed convectors to 603 - ROOF BATTENS
co tuctthepmject(Sec.70a4,BuaincssandProf.uMn e:IThe ConvectoriLt. 604 — ROOF IN-PROGRESS
cane Law does not apply to m Owner or p open o ilds or impm es thereon,and.
whoeonaacu for such jeers withaeon ct lice d or an the Contractoh
Licenx Law.
' t]Iame/x�emPt un r et. a ,B&PC for this mason
own(.24 A Daly 7/?/0
I,— WORKER'S COMPENSATIONDECLARATION
I hereby affirm under Penalty of pc jury one of the following declarations:
I have and will mountain a Certificate of Consent to self-insure for Worker's Compcm
cation,as provided for by Section 37W of the laver Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance.as requimd by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compenutiou Insurance carrier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EDC EM MON FROM WORKERS'
COM PENSATION INSURANCE
(Thu section need not W completed if lbe permit is for one hundred dollars($100)
or Icu.)
1 cenlfy that in the performance of the work for which this Permit is issued,I shall not
employ any Person in any manner x a m become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.arta making this Ctnifinte or Exemption,you should
become subject to the worker's Compensation provisions of be tabor Code,you must
.J O fartbwi Or comply with such provisions or this permit shall w deemed mvoked.
Z'7 CONSTRUCTION LENDING AGENCY
(•" l toothy affirm that untie is a amtruti0n lending agency fm the performance of
6aithe work for which this permit is issued(Sec.3097.Civ.C.)
W Under's Name
D'
z Underi Address
>
C.1 Q 1 certify o C I have read this City
and.tin.and mato Nat the aw.e Information mtniun is
0 U torten.I agxc to comply with all city and mpmy statim of and cute laws relating e
Q V abovo-gcmionedtioaend hereby authonimreoses, vcs of this city to corer upon the
r1 awveties judgments,Cos.
for inspection which
may
(Wt)agree to save,indemnify and urep harmless the City of Cupertino against
HN incoisequenc of thegrassing expcnsesmit. mayinany wayaccrue against mid City
LJ z APPLI ANT of UNDERSTANDS
this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
` SOURCE REGULATIONS.
� ? Dam
�3 o Re-roofs
Si t HAZAR60 S MATERIALS DISCLOSURE Type of Roof
Wi twapplicanturfulum Nildingacupanistoremhandlchmardausmavdal
as,defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
vele.Section 25532(a)?
❑tees rna All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
nP s v a Air Qu or devices which g p
I hazardous air contaminants u defined by me Bay Arca Air Quality Management all new materials for inspection.
ct? � /'
❑Yes t$No k
Ihavc sad the hvaNt 711 mdals reyvircmenu under Chapmr695 Cf dtc Califar- s
nia Health&Safety Cock,Sections 25505.25533 and 25534.1 understand that ifthc wilding G
Jons t curtemly hole a tonan4 Nal it is my ms nsibility to notily the acupanl of the
y e Iihmh sew tp arta erdfita¢rragopangy. Signature of Applicant Date
�- 7�3�b
owner ur anmarivcd scent D„e All roof coverings to be Class "B”or better
Community Development Department
Building Division
�I City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
U P E IST I N O Fax: (408)777-3333
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 LC.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: (>.l,l.jrP v.-H v\ p
Roofing Company Name:
00ll S
Applicant's SignaturX_" _A Date: � p 3
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO /
REROOF ° 3CITY OF
J
CUPERTINO PERMIT APPLICATION FORM
APN# S_ ( O D o Date: 7 3 O
Building Address:
o J� Cw �e�f; � o A- "0
Owner's Name: Phone#:
G�- cQ 2 11J �� vIn l r '✓
Ac)y— 2�_Z - S
Contractor: Phone#: License#:
Contact: Phone#' Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles t!(, 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: p
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are an restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
O .
Qty. if
A licable Fee ID Fee Description Fee Group
BPERMFEE Bld Permit Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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