03110012 I
CITY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION `•,`.'':
BUILDING ADDRESS: - PERMIT NO.03110012
OWNER'S NAME: PERMIT MUE DATE
RJAY
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0
J00 LICENSED CONTRACTOR'S DECLARATION Job Description
U F 1 hereby affirm Thal 1 am seemed under provisions of Chapter 9(commencing p
jam`,' with Section 7000)of Division 3 of No Business and Profession Code.and my license is
„ Infall @real come`' REROOF c ®.®■ C®
License Clan Lic.pr114^
Das TSDECLContractor r ■
e ARCHITE use DECLARATION
G�� 1 uWcbibinJ my plans shall M used as public records 2003
o Licensed Professional
NOV 7
Oat I am exempt
from
DECLARATION
n0 I hereby affirm that 1 1. exempt(rum Ne Contractor's License Law for the ANG
p o� following,irsa Peeniutocos5,Business and Co de:Any city orcoumy BUILDING
<m which requires
a Permit ra construct,the slur,intfuve,demolish,or repair any ahumure �.a
YZY triton itaissumue,also
prarsO act the Provisions
nt Offorstach e COmocrmifaofentele a,Law(Chamem
E'n (commthat he escingwJpuection7 lopmvivision3o(theBuacmalunittnuleiwfChapsr9 Sq. Ft. Floor Area Valuation
c l- (commencing stomp,
Section it)NDiasis f J t o al aged camp or.APotan vi Cork)m
��$ that he is esempl thertfum and the baso for me alleged exemption.Any violator of 37519004 . 00
Scott..703 L5 by any applicant to,is issearnit subjects par appliespit I..civil bill,of APN Number Occupancy Type
not more man five hundred dollars a50B. - - P Y - ----
❑ 1.as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the swmute is net intended or offered for sale(Sec.7044,Business
and Professional Code:The Contractors Liceve Law Lura not apply to an owner of Required Inspections
property who builds or improves mereon,and who docs such work himself or through his
awn employees,provided that such improvements arc not intended croRered for ole.IL
however,the building or improvement is sold within one year of completion.the owner.
builder will new the burden of proving mat he did not Wild or improve fur purpose of
sale.).
as owner of the property,am exclusively contrecting with licensed cunvacmrs les
moss La me es jet(Sec,]04q Business antl rt,who
ds oe.)Thcm thereon. ni
Genu law contracts
f not apply man owner of property who builds or improves Contra,and
whoonse L` ts for such projects with a contractor(s)licensed pursuant m the Convenor's
Licence law.
❑lam cue under Sec. 4 se B&PCfarIlio.oon
OwnDate
WORKER'S CQ111PENSAM9.151EPWATION .. _
I hereby affirm under penalty of perjury one of the following declarations:
I bare and will maintain a Certificate O(Conum m sel6insurt for Workers Compen-
sation,as provided for by Smile.3700 of de Icor Code,for the performance Of Ce -
work for which this Permit is issued.
1 hoe and will maintain Workers Compensation Renta a,as acquired by Seetian
37W of the LaorCode.for the Performance of the work for which this permit is issued.
My Workers Compensation Inhabiter anter and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thessectionneed notiecompleted ifthe Permitisforonehundreddollar (glRp
or less.)
1 cent fy Oat in the Performance of the work for which this Permit Is Wood,I shall not
employ any Person in any manner so as at become subject to the Wmkeri Compcnsadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL alter making this Ccni foal of Eumpfom you should
become subject to the Worker'a Com funsedon provisions of the Labor Code,you must
,z fonhwi th comply with such provisions or this permil shall be deemed evoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby aRrm Out then it a eonstructinn lending agency lot me Performance of
Ya > the work fur which this permit is handed(Sec.3097,Civ.C.)
JJ Undcrs Name
z Lenders Addreas
J 0 1 unify that I have road this application and show that the move information is
F' correct.I agree to comply with all city and county ordinances and state laws relating to k
building convection,and hereby autharim apreuntallM of this city to enter upon the
Vforinspection
Thourperyy hit",judgments,
agree to,cove,indemnify and keep hay in an rer City o(Cagainst against
' v3 liabilities,judgments,costs and expenses which they in any way accuc against aid City .may
J7 mcunsequeneeof egrantingufthisphmiL (0?1A
U f/�
r7 APPLICANT DERSTANDS AND IL COMPLY WITH ALL N IN-POINT Issued by: Date
SOURCER LATIONS.
,//a Re-roofs
aluric of Applimpa/Comracmr to
HAZARDOUS MATERIAE$DISCLOSURE. Type of Roof
WIII the applicant or future building Occupant store or handle hamdous mawriul
as defined by the Cupertino Murldiati Code,Chapter 9.13,and the Health and Safety
ode,Section 23532(a)7 All roofs shall be inspected prior to an roofing material being
❑rat4 u P P Y g g installed.
Will meaPpneantorrum..Wilding«rrPantase equipment ordevicnwhich
I(aroofisinstalledwitboutfirstobtaininganinspection,Iagreetoremove
I[haaardnoe+ir contaminants is Jefned by the Bay Area Air Quality Management all new materials for inspection.
istrlct7
0 Yes �Ahi
I have real the h...ad, tacdals requiremcntsunder Cltapter,6.95rfthe Califn. t ,-
nieHralthd: ty COJr.Sttvon25505.255JJ and 25534.IunJcreaM thider, Willing )'
Jim nal c ntly haw a anon,,Na i u my responsibility b notify ire occ ibent Of 0
rtyuiu tswMrnmuRWmet ucerfacertificai cc aver. Signature ofApplica : Date
Owner rer ortamircd agent / I. All roof coverings to be Class r$t Or better
Community Development Department
n
f Building Division
City of Cupertino
f i } 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF
Fax: (408)777-3333
U P E��I N O
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.
L 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,A /�
Job Site Address: l /� 0 o-�0 f7�t- ( LA.0 21T`ab C6 LTV(P
Roofing Company Name: rl �»✓
A scant s Signature: Date:
Grego
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
p D
Building Address:
Owner's Name: Poe#t
c a (4
Contractor, Phone#: License#:
I ro ) -Aw
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑/Built-Up roof
t�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 Cupertino's Tear Off Policy: ❑
job Description:
st
Residenti Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any rest ' on
Cost of Project: y Type of Co Occupancy up
Qty. if
A cab e 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