03090057 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CO1VTIt�,CTt7R�INFOYtMATI,ON
BUILDING ADDRESS: DAN ELLIOTT ' S ROOFING CO PERMIT NO.03090057
OWNER'SNAME: 2669 COIT DR PERMIT ISSUE DATE
ONE: (408) 559-7327 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.00 LICENSED CONTRACTOR'S DECLARATION O O O
d I hgrepy affirm that I am licensed
��.e�nyp{r provisions of chapter 9(commencing Job Description
.zw with SectioA'rIXXq of Division 3 orthe Bt and Pmfcuions Cnde,sud my been.is
a
in to"'
forte on c REROOF
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a - Lk.N PINALSO
�Fp Dalc - Conlnc
p7WARCHITEC7TSD C TION
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1. demand my phos shall le trod u public records
;p LicensedPmNsahm.1 , OCT 0 2 2003
OWNER-BUILDER DECLARATION
�<q 1 hereby affirm that I am exempt from the Contractor's License Law for the '
00 following mason.(Section 703 1.5,Business and Plofeminns Code:Any city or county BUILDING
e m which requires a permit m construct,alter,improve,demolish,m repair any structure
Uzi prior to its Issuance,also requires the applicant forsuch permi0u file a signed statement
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that he is licensed pursuant m the priviatom of the Comrwier'a License law(Chapor9 Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 o(Nc Business and Professions Code)or
$ Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemtit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than rive hundred dollen(I500).
❑
I.asowner or be property,or my employees with wage.utheinole compensation,
will do be work,and she structure cture is not intended or offered forale(Sec.70M,Busies. _ FRAME
and Profcssimt,Code:The Convector's Lt..law does not apply to an owner of Required Inspections
pmpeny who builds orimproma Bcome,and who doessuch work himulf or through his 307 - INSULATION
own employees,provided that men improvemenu are notimanded fir offered forsak.If. 60I — ROOF TEAR OFF
h.wewe the building or improvement is said within one year of completion,the owner.
builder will haw the burden of proving that he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
"l`')' 603 - ROOF BATTENS
❑I.a owner of the property,am exclusively contracting with licensedThe
m
construct doesnon(Sec.T0e w.,of
and Professionsds.r Toe Cothermn,Li- 604 — ROOF IN-PROGRESS
amu Law coca not apply Mae owner of property who sed p or Improves thereon,and
who contracts for such pmlecu with a contnnor(q licensed pursuant to the Contractor's
License Law.
❑ I ore eaemPl antler Sec. .B&P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby 4fRM under penalty of perjury one of the following occlusions:
1 hoe and will maintain a Certificate of Consent o self-imum for Workei s Compen-
IC-111
ion,u Provided for by Section 37M of the labor Code.for the performance of the
rk for which Nis permit is issued. .
1 Mare and will maintain Workers Compensation Insunna,As required by Section
0 of the labor Code,for the pcRormmce of Ne wort Nr which Nia permit is issued.
Worker pe.ti.n Ins. ace .rand Policy umhoram:
rrier. alicy t�?d,t 72_7X
CERTIFICATE OF E%EMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hccomplewd i(the permit is for one hundred dollars(II00)
or loss)
I certify that In the perfnrmanee of the work for which Ibis permit is issuod,1 shall not
employ any person in any mariner so as to become subject o the Workers'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.Jr.after making this Cenlriesm of Exemption,you should
become subject to the Worker's Compensation,provisions of the Labor Code,you must
.J O forthwith comply with such provision or thio permiuhall M deemed revoked.
Z "" CONSTRUCTION LENDING AG ENCY
F+ 4 I hereby affirm Nat marc is a construction lending agency for Be perromance of
gLa > Be work fur which this permit is issued(Sec.3DJ7.Civ.C.) -
ILI Q landcis Name
0. Z Lenders Address
V 0 1 certify Nu I have read Nis application and state Nat No above information is
V, F correct.I agree to comply will all city and county on inanecs and State laws relating to
0[, building construction,and hereby authome represematiwx of Ni.cloy to enter.pun he
W ahove-momioncd property for inspection proposes.
(We)agree to..w,inecmmfy and keep harmless the City of Cuponin0 against
liabilities,judgmcnu,costs and expcnaca which may in any way accme against City
U z in consequence of the granting of this permit.
ANT UNDERSTAN AND WILL COMPLY OF-L-0
ALL NON-POINT Issued by: Date
E 10 S., ! / _
Re-roofs
Signature of ApplicanVCOnuacmr Dau
HAZARDOUS MATERIALS DISCLOSURE - Type Of Roof
Will Nc applicant or forum building occupant nom or handle haruduus meudal
As defined by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
cme.Section zss3z(a)+ l` All roofs shall be inspected prior to any roofing material being installed.
]Yes p]No
Witt the applicant orr fu\lure building occupant use equipment or devices which Ifs roof is installed without first obtaining an inspection, Iagree to remove
it h.rerdnus air musho mu as defined by the Bay Arta Air Quality Managcmcnt all new materials for inspection.
isuin7 �' /' -
❑vc.
I have mad the havarduus materials requirements under Chapter 6.95 of the Califor- T-
niuHcalNA SafetyCtdo,Seedom 25505,25533 and 25534.1 undervad Nal ifdu building
J not vrcnlly haw a mmol,Na i is my maponaihility w nodly the returner of the / -
reWuw ' oat mm p' rissuancenfa Cenifica o _ a=r2 g ure of Applicant Date ,
0 ncrmauthonmJagcm Data J 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
4UPEkTINO Fax: (408) 777-3333
Building Department
artment
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) '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 theabovestated policy Ion re-roofing.
Homeowner's Name: Ms i lie C� 1 V Y\a l' 1
Job Site Address: oq O � D�X 1 Y\P_ T\v`Q
Roofing Company Name: EAt 0 S r,�,m�
A plicant's Signature: Date:
\�lloC.lhlD�Xl
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF a 3 os
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
10go1 oxine �r�
Owner's Name: Phone#:
(0 vtl
Contractor: Phone#: License#:
ft.AA to . IZ a-�- (o qO&-S5 1-7SI-1 (o t13 g
Contact: II � Phone#: Cupertino Business License#:
0..r or l.Ovlt6
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
® Asphalt Shingles a Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ; ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings U3 ini ❑ Provide I.C.B.O.Report* ERS 4l4
0 To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
re.mo�.e �wo � � s ��ber lass � ns�l aec� . �'�bec lass
Residential Commercial ❑
Fire Zone: Yes ❑ No ® Confirmed with Plan Dfpt. if
there are any res tions:
Cost of Project: 1 Q O� Type of Construction: Occupancy gr up
1A.mq—
Qty.
ApplicabIql 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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