04060029 CITY OF CUPERTINO � "' � Y�' '`^�r �
_ BUILDINGDIVISION PERMIT !�qN��.�T�dRINk�kCl,,.���x'.Tf�N�'_ .
BUILDI G ADDRESS: PEItMRNOD 4 O 6 O O 2 J
OWNER'SNAME: , PORMITLSSU0OA18 '
JOSEF & LEA B
g; SANITARYNO. CONTROLNO.
ARCHI'IECf/ENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
�00 LICENSEDCOMRACTOR'SDECLARATION� � o 0 0
��� 1 hcrt�y affvm Ihe�I un littnud unJcr provixions nf Clup�cr 9(commrncing Job Description
wiN Semian]O(N))of Divirion 3 of ihc Busi�u�nd Profasiunn Code,end my licenec ia
��� ��mntoR�a�a�rr.« REMOVE & REPLACE ROOF ������' 'u'
j�z Licenu Qss� Lic.x
��p Da¢ ConlrzcWt .
ARCHffECI'S DECLARATION
�y � IunJenunJmypbnnehallheusetlespuM1licmcnNs � �UL �� ZOO�
�ya
;o� Liccnud Pmfcuinn�l
3 OWNER-BUILDERDECLARATION ��' w
� 1 hcrchy alfirm thel I em ucmp�fmm Nc ComrecmYc Liccnw Law far�hc �■ p���
O D fallowinS 2%+�n(Sccuun t07 L5,Businas and Pmfusinns CaJe:Any ciiy or couniy a�
y$� which rtquirrs a pemi�io conrwn,el¢r.impmw,demolish,nr¢pair iny stmcWrt
yzY prionniuissuencc.elsumyuims�hc�pplicanlforwchpermitwfilcasipnc�iu¢mcnt
me �heihcisllccnsc�pursuenunNepmvisiomnf�hcConlmcmieLiccnrclaw(Chap¢rY Sq.Ft.F7oorArea Valuation
yF� (commencingwiNStttion7000)nfOivuionJnfNCBusincseenGPmfcuioniCMc)ur
i�� ihet he u exempt Nemfrom mE Ne buis for 0e allegeC eumpuon.Any vlolaibn of
Sepion 70SL5 by eny appliwm for e pmmit mbjecu Ne applicem w a civil pentlry o! &���Q Q QCCU BIIC 0
notmomNu�mehu�dmedonars(Ssoo). P Y�'P
❑I.u owner of lhe pmpeny.rn mY�ploycn wiN wgm ea Neir sole compenm�on, '
will do�M1c waek and Ne iwclurt is natin¢ndc0 oroRemd fonele(Sec.)044,B�tlnese
enJ Pmlessions Code:The ConvaaoYs Lianse Law doca nof appty b en owner o( Required Inspections
pmperty who builda or i m promn Ne¢on,enE who does meh work himeelf or Nmuy�Aii
own emplayccs,proviUeJ Na�nuch improvemenu ue no�in¢n0etl oroRemd formle.If.
however,Ne Luilding or impmvcmenl it solE wiNin ane yeaz af compleuon.Ne avner� ,
boilder will heve ihe Wrden of pmvin6 Nel he did no1 WiIJ ar improvc!or puryose of
ealcJ.
�1.�mvner of Ne pmperly,em excluaively canlnaing wilh licenxd ronvecbrt lo
conewe�Ne pmjecl(Sec.70C4.Buainrsti enE Pro(caions Code:)The Conuecar't Li� .
' cenulawdocanolapplyloanownuofpmpenywhobuilGsarimproveslAereon,mC, �
' whoconmcbforsuc�projecLtwilhaconv�cmr(Qllceve�pumuenuolheConlroMor�
Lkenm Iaw. '
❑Iomexem ��unptlerSec. .B&PCfo/r�Niamuon �
. Y- 7��De¢ `/—��
ORKErt'S COMPENSATION DEC ATION .
1 hemby��m under pentl�y af perjury one o(Nc @Ilowing declwGone: � �
haw nnJ will mwnuin a Ccniliu¢of Co�uent w eelGinsum for WartelsCompem
emion,ae provided for M1y Sectlan 7]IIO af Ne Isbar Codc,(m Nc pcAa�meMe of�hc
work for which Nis pnmit is iuecE.
❑I�ave and will meimein Worker'e Compensation Insurance,u myuircd by Sectlan
;]OOofNeLabarCoEqforNepeefaemaneeo(IAework(orwhiehNifpemii�isissmd. � � "
My Workeh Cnmpenseuan Ineure�e nrtiv md Policy num�cr ve: ,
Certitr. Poliry No.:
CflRTIFICATE OF EXEMP170N FltOM WORKERS'
- COMPENSATIONINSURANCE .
(Thissectian nced no�M complekd if�he permi�b foronc hunEmE Jollers(Silp)
orlrsi.)
I ccnily�hoi in�hc pvfoemencc o(Nc work for whi<h Nis permi�u issucd 1 shell w�
employanypersoninanymenncrsnaziobccomembjcciioNCWarkcrs'Compensa0on '
Laws of Califomle.Dea
ApPlicint
� NOTICE TO APPUCANT:If,af¢r makin6 Nla Ccnifica¢af Ezcmp�ion,you shoulJ
bttome su�jcn m Nc Woder'a Compensetion pmviaiom of Ne Iahnr Code,ynu mua
.J O fon�wilA camply with twh pmrisinm ar Nin permil ah�ll bc EccmcA mvnked. '
,,,'Z,� CONSTRUCI'IONLENDINGAGENCY � '
[—ii-N+ IherthyolTrtmNnNercis�co�Wninniendinialentyfor�heper(oemanmuf ,
Ci� Nc work fur whicM1 @ie pnmi�i�iuucE(Sec.J099.Civ.C.7
�� LenacisNunc ,
,'z LcndchAdd�eas
V Q 1 cenify J�at I havc rcad Ihia applia�ion ond amk�hat thc ebovc info�matiun is '
�� cortccl.I egme m wmply wiU all city ena counly aNinencm enJ au¢lavn rcla�ing lo
QU buildingconswnion.enGhe¢bymNanxrcprcaenutirvafJ�iuitymcn¢rupo^Nc
W above-menuonedpropenyfarimpecYonpurpmes
(We)agme lo neve,indcmnity and Yccp humlev IM Cily of Cupertina e6einsl
�jj Iiebilitiu,judgmenu.co�umdeepcnsrawhichmeyinenywoyeccrvc�CainsiaeiGCi�y
V`z inconxqucnccalNegrantinguflhispermit.
^� APPUCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT Issued by: Date
SOU R ULATI NS. �� �
Re-roofs
Si aW fApp HAZARDOUSMATERIALSDISCLOSURE DeN TypeafRoof
Will Nc epplicanl or(uwre building occupmt etoro or hendle harudous ma¢rid .
es Eefincd by Ne Cupertino Municipel Codc.C7upmr 9.12.md�he Hca1N end Sefety
ode,5cc6on25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Ycs �No
Will�hc applicant or fuwrc builJinC�cupent ute cyuipmcnl ar JcMccs which If a roof is installed withou[fttst ob[aining an inspection,I agree to remove
��azerGnus airconuminanu ss JcfinN by Nc Bay Arta Air Qualiry M�mScmcm all new materials for inspection. '
rsvin?
t+ ❑Yca �fVu ' ' �
1 hevc maJ Nc havaMous mamriala mquiremcnu unJcrChnpmr6.95 of Nc Glifor-
nia HcaIN�Sa@iyCotic,Scc6ons 8505,355J]and255Jd.1 unJcrswM Nazif Nc huilJing
dme no�curtcn0y hvw e mvn�Nn ii is my respoviM1iliiy w muty Nc occupent af Nc
myvi � n��nm�,�mm<< �ao.w�,s��«or.c�mn�,�oraa��Y. SignatureofApplicant Date
Owncr amho'.cd e6enl o„� �y All roof coverings to be Class "B"or bet[er ,
• � CITY RE���RTINO Qv�
� cirro �)��" �
�CUPEf�TINO PERMIT APPLICATION FORM �
APN# � ,�- � r, �� Date:
�-� - D�
i Building Address: ��LK y �N/�I-�-/ �.j jJ�� ��/`p
Owner's�i e: Phone #:
�s�- � L�.3� �Ronr+�,�
ContractNy Phone#: License#:
���12/711�p-75f�
Contact� d-�F ��N�� Phone#: ��o� Cupertino Business License#:
�S�'-D
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
r ❑ Wood Shakes ❑ ood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
mber of existing coverings ❑ Provide I.C.B.O.Repor[#
To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Com 1 With Cu ertino's Teaz Off Polic : ❑
Job Descripti�: '��h0-!�� �/� �;�7'��� E�4S7'1/✓� 1i�r7�
O
Residential� Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with nning Dept. if
there are estrictions: LJ
Cost of Project: /'� �� of Constru io .� Occupan gr p:
� �
Qty. if •
A li e Fee ID Fee Descri tion Fee Grou
BPERMFEE Bld Pemut Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUII,DING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
�
S
� Community Development Department
Building Division
� ���' � � r: City of Cupertino
10300 Torre Avenue
� Telephone: (408) 777-3228
CITY OF Fax: (408)777-3333
PEI�,TINO
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 specifica6ons on re-roofing.
2. New roof coverings.shall not be applied without first obtauung all inspeclion
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-progressinspection 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'/a " 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 Nam� NC�.�-�� `� L�' , ����'�
Job Site Address: `'� j��� ���'K � ���
Roofing Company Name: '� �W���
r 2 O�
A plicant's Signah� �� Date:�
\�t/Qs1^10��1 �
� Greg eel
Building Official
Revised 1/30/03
Prinfed on Recycletl Paper