04050122 CITY OF CUPERTINOy-�^}�a rg. 77 y77O
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BUILDING DIVISION - PERMIT CON`T1"0TQlt lkal ltAT',lC).1.1 N,�=
BUILDING ADDRESS: PETERSEN—DEAN INC PERMITNcb4050122
OWNER'S NAME: PERMITISSUEDATE
KENNETH
ONE: SANITARY NO. CONTROL NO.
(510) 494-9982
ARCHITECI9ENGINEER: - BUILDING PERMIT INFO
BLOW] E PLUOM9 MEOCH
y O O LICENSED CONTRACTOR'S DECLARATION
1 hereby sifted Net I am licensed under provisions of Chapter 9(commencing Job Description
with&,it..7W).lDivision Sof dee Business and Professions Code.and my license is
`y�zin full force and effe
License Clsss �`''-34 .a `lL��� REROOF
n E Date untrut
Q
AR Rgy A
83 Iundcrsund my plans alMuuJupuMic me Js
7WyU
Licensed Pmfcuienel
3 OWNER-BUILDER DECLARATION
<� I herchy affirm that I am exempt from the Conuaeem's License Law for the
a O following reason.(Section 7031.5,Business and Professions Code:Any city or county /
which acquires a permit to ennmrocl,alma Improv,demolish,nr'.par'.,atructo. �q _
iZ.2 prior m its usommce,xlu requires theapplicanl for such permit ho flea signed smtemem .a,
p�Q that a is licensed pursuant in the provisions of the Convector's License Law(Chapter 9 Sq.Ft. Floor Area �� Valuation
of (commencing with Section 7")of Division 3 of the Business and Professions Cow)a,
E R S R that a is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant in a civil penally of 3 7.�PN19>fl3ei0 0
not mom than five hummed dollar(SSW). patty Type
❑I,mowmrofthepmpmly,wmycmployceswithwagesmthelrsolecompanmtion,
will do the work and afternoon.isnot intended or offered for sale(Sec.7046,Business
and Professions Code:The Comeame.Lt...Law does not apply In an owner of Required Inspections
property who builds ortmproves themon,andwhe docaauch work himselforthrough his
own employees,provided that such improvements secant intended aro@red foraele.If.
howevm.me building or improvement is sold within one year of completion.are owner.
Wilds"
will have the burden of proving that be did not build or improve for purpose of
ask.).
❑1.as owner of dve property,am exclusively contracting with licensed corrome m to
construct the project(Sec.7044.Business and Professions Cade:)The Courpecon6 Lt.
came Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects wide a contractor(s)licensed pursuant be the Contractor's
License Law.
❑1 mm exempt under Sec. ,B k P C for this range
Owner Dem
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of the following decimations:
1 haw and will maintain.Certifies'.of Consent m self-insure for Workers Compcm
ration,se provided for by Section 3700 of the letter Code,for the performance of me
work for which this permit is issued.
1 have and will maintain Worker(Compensation Insurance,as required by Section
7110 of the Labor Code,for the performance of the work for which this permit is issued.
MyWorkctsCnmpenre��titmen�"l�nsunnacanierandPolirynumW a
Cartier. fAla•r P1 viryaft• Policy No.:
Z 1 OS
CERTIFICATE OF EXEMPTION FROM WORK Rs'
COMPENSATION INSURANCE
(The,union need not a completed if the permit Is for.nchundreddollam(Sino)
or less.)
1 certify the,in the performance of me work for which this permh is issued.l shall not
employ any person in any mannerad m'.become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL ether making this Cenificam of Exemption,you should
become subject to the Workers Compensation previsions of the Labor Cade,you must _
rJ Z forthwith comply with such previsions or this permit shall he deemed revoked.
O CONSTRUCTION LENDING AGENCY
Ihereby a?rm mat mere is.commrctime lending agency far to performance of
ce> me work fur which this permit is;issued(Sec.3097.Co.C.)
QLender's Name
ru7- Z Lender's Address /
U Q I Cerree that I comply
mad all
city
and nun and slaty that me save Information riing Ir
C)F cotta 1 agree to comply with all city and county eNinsncer and rete laws retailing upome
�O builw-racremoudiogand hereby farguredan prposesemesivnafdeisclty to enter upon me
ab.vc(We) gdproperty fm imnifyan keeptha. j �
(We)agree ee save,indemnify and keep harmless the City of Cupcninu against �"V' VfJV (/
liabilities.Judgments.casts and experses which may in anyway accmc age ran said City
V z in consequcme of Jla gmnitng of lhu ih.
�"' APPLICANT ERSTA ILL C PLY WITH ALL pyyl11�N- DINT Issued by: Date
SOURCE R LATfO Sv/ 1
/ G Re-roofs
signnone al'ApplicandCon,ru,or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building acceptor seem orbandlc hmardous malarial
as defined by the Cupenlnunminor Code,Chapter 9.13,and the Health and Safely
eaa.Seebad 35532(.)+ - All roofs shall be inspected prior to any roofing material being installed.
❑Yes _
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applican r fwurc building occupam use equipment or devices which g P g
Wit ha'rallous air conmm ns as defined by the Bay Area Air Quality Management all new materials for inspection.
District 4
❑Yes No
I have mad me hmatdous nowrials requirements umber Chapter 6.95 of the Califor- a,
riannothdi It
Code,2"' 25505.35511 and 25534.1undemtea thmifthc huiiJing SCG y,�,D-
dean not curenJy have rent,that' is ponsihilil nodi me esu and of the
requirements
which be u ccofa Cc lease of 6ccu ,�J Signature of Applic t Date
owner or amadzadagnn Dam C'� All roof coverings to be Class"B" or better f
05/16/2004 12:48 5105383262 �-ESALITIES 1W PAGE 01
t"'tc�''r."'- •Ylt.a.�.. .p,�:.i,y M.n.P ��1�
4b:tmo CA 95014
Teacphnao(408)"'-3228
I Fm(408)7''•3333
Or
CUPERJTIN
Buildin De artment
JOB ADD E S: PERMIT#
/d6 9/ �Yllitwl� ���-c--
0 N PHONE# 45o
X GENERA NIRACTOR: FAX#
;t I am not us rlgl any subcontractors: _ 2 ! 7-
Signature Date
Please chec a; licable subcontractors mw com lew the following information
SU:CONTItAC'TOR BUSINESS•NAME BUSI.NESS LICENSE #
Cab ts.ds Millwork .
ce t Finishing
Elec cal
Excation
F
o
• eum/Wood
/ Glazing
ea '
ation _
aping
ental Sheet Metal
p g/ Wallpaper.
Pav
Mu*lb
Pl Bring
in
RV1in
t -7tor Signature Date
41 Io/28N3
'I I
i
I LLOB-464 019 1d30. d00?J3a RiE :LO b0 LT Rew
Community Development Department
Building Division
' arr City of Cupertino
10300 Torre Avenue
OCITY OF Telephone: (408)777-3228
UPEkTINO 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:
Job Site Address: ID,S
Roofing Company Name:
Aplicant's Signature: Date:
• Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO pzf p��la�
0YOFREROOF
CUPEINO PERMIT APPLICATION FORM
APN# _ Date:
Building Address:
/06- �w
Owner's Name Phone#:
S?6 - GG28
Contractor: Phone#: License#:
/o Y9�f - a 8 Lf b 81 t 7
Contact: Phone #: Cupertino Business License#:
Type of Root Covering:
Existing: Proposed:
`k Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles `fel^. Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings Z ❑ Provide I.C.B.O.Report#
'LK To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Po'ic
Job Des 'pti
D r
Residentia Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anv restrictions: LJ
Cost of Project: i Type of Construction: Occupancy group:
Qty, if
Applicable Fee ID Fee Description Fee Group
/ BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
I BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
ism