03030079 CITY OF CUPERTINO �' «'°' m'" '�' `'~ ° ' '`' "
BUILDING DIVISION PERMIT CTORINk0O !,KION
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P811ILDINGDDRESS: GROMO ROOFING PERMIT NO.
ME: 121 W WASHINGTON AVEC
.qE; SANITARY N OL NO.
(408) 746-2075
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u 0 o LICENSED CONTRACTOR'S DECLARATION O O O O
F I hereby.flues that 1 am Bwnsed under pmvislons of Chapter 9(Commencing Job Description
airs with Section 70130)dDivplon 3 office Busincs, dPmficCderm Code,and my license is r�=�tlp p W
of infullf.V�epd.ffett 7J�'J3 If II�Y,I6��L
qi ueensec.N33" - tie.« REROOF
n t O Dem Cunnor
i
A CHITDCTSD A MAR 2 0 2003
undemand my fiduu shall ose
ud arp s menrds,
>wV
t o. Licensed Professional
os
OWNER-BUILDER DECLARATION G
,BUILDIN
I F I h..hy Off,.that 1 am exempt from the ComnmLi
m'. cense law for the BUILDING
Y`7
no following mason.(Section 7031.5.Business and Prurient.Cede:Any city of County
3$ which requires a permit m construct,alms.improve,demolish.or repair any structure
-iy prior m is issuance.also requireLM applicant for such permit to rile a signed statement
£ < that be,is licensed .act to the provisions of the Centractots littnse Law(Chapter 9 Sq. Ft.Floor Area valllallOn
y (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
$ Neth is exempt rh^nfroes and the buss for the alleged exmnption Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A.y7.t {,,
not more than five hundred delta.(S500). 34$2v}`JWBF6r 00 Occupancy Type
❑1,as owner of the property,or my employees with wages as their mm compensation,
will do the work.and the strumum is out mended or offered for Wt(Sec.7W.Business 305 FRAME
and Pmfassimu Cute:The Committees License Taw does rut apply to an owner of Required Inspections
,.,ny who buildsm improves thereon.andwh,doe.such work himself.through his 307 - INSULATION _
own employees,provided thatsuch improvements are not amended oroffered for We.If, 6O1 — ROOF TEAR OFF
however.the building or improvementmu Is sold within year of Completion.the owrco
builder will have the burden or proving that he did not Wild or improve for purpose of 602 — ROOF PLYWOOD NAIL
We.).
❑I,as owner of the property,am exclusively contracting with licensed Contractors to 603 - ROOF BATTENS
construct the pmjcct(Sec.7D44,Business and Professions Code:)The Conmetor'a Lb 604 — ROOF IN-PROGRESS
Cone law does not apply to an owner of Property,who Wilds or improves daemon,and.
who Concocts for such project.with a com.am(s)licensed pursuant to Ih Convector's
License Law.
O 1 am exempt under ga. .B k P C fm thb ration
Owner Dam
WORKERS COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of tits following decimations:
have and will maintain•CcelImam of Consent to self-insum forWodmes Comis - -
u0on.as provided for by Section 3700 of the Labor Code,for the performanCo of the _
weak for which this permit is issued.
@at ban and will maintain Worker's Compensation ns nec,ss required by Section
37W of the labor Cocc.for the performance ofthe orwhich this permit is issued.
y aster's Compensation insrace
unCarta m
Carrier and Policy number :
r: rU ✓
MeT- re /V^ 0 Polmy No.:
CEKDFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Otis section need oat no Completed tribe Permit is fmonehundmaidmlla.(SIM)
Car leu.)
1 artily that in the penri m Lice of the work for which thb permit it burned,l a ndl not -
employ any Person inanyq�m o o�ub the Workers'Corrismation
1..1 California.Dam
RR -
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Ldbm Code,you muss
.JO forthwith comply with such pr..ideas or this permit mail be domderevoked.
z ti CONSTRUCTION LENDING AGENCY
f< I hereby affirm that them is a convection lending agency for Ne performance of
the work for which this permit is issued(Sec.3097,Civ,C.)
4 Q Lender's Name
dander's Address
t)Q 1 certify that 1 have read this implication W auto that Ne move inlmmaon u
Or Counsel.I agree m an
comply with all city and county ordinances and state]am lamisting to
U building convection,and hereby authorrm representatives of this city to enter upon the
N W cove-mentioned propertycosts
for infection purposes
(We)agree to save.indemnify and keep harmless the City of Cupertino against
nFih in Consequence fd,cossand of this permit. may inany way ecerve against said City
V z in consequeme of the gnming of this Permit
'-' APPL1¢ANT UNDERSTANDS AND WILL COMPLY WITH ALL -POINT Issued by: (a Date '
YOURo4E REGUl.AT10f1S.. 7 y O
Inaaaluum of ppphcanUContracam ���'/// Dame Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumes building Occupant store Orion, hazardous material
u defined by Ne Cupertino Mu 'ciPal Code,Chapter 9.12,and the Health end Safety
e.Ouon33572(.)? All roofs shall be inspected prior to any roofing material being installed.
Yea Nu
Will the applicant or future Wilding occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
rely hatardous air Commitments as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes I,P]'ICp�-
1havesadthehwasdouam.uuAs mquirementa underClupter 6.95 of du Glifor.
nice Health&Safety Code.Section75505,25533 and 25534.1 unOc.mndust if the ImKdm� � /
does not currently hove a tenant,that ii u my msP9nsihilit noufy the occupant of the J�
my mencnts which must h mut prior to I.somm of•Certifies f Cupenry.
T Signature of Applicant - Date
r
Owner oraummicadagent Dam All roof coverings to be Class"B"or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
C U P S kT I A 0 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 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: vi 1-70 2
Job Site Address: 10/S K� f✓ rJ D Zg
Roofing Company Name: 6/77 hJU ROO .e
A plfcant's Signature: �� Date: 3 /Y t9
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper