05040134 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION :
BUILDING ADDRESS: PERMIT N0,
05040134
OWNTAER'S NAME: PERMIT ISSUE DATE
NE: SANIRY OL NO.
ARCIfITECTIENGINEER: BUILDING PERMIT INFO
BLDGPL
ELECT UMB MECH
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y0o LICENSED CONTRACTOR'S DECLARATION JobDescri tion
d I Wmby affirm Nas I am IiamcO under pmvisiom of CMpter Y(commencing P
With Section 7BIXBof Divtxfon3orN Businesxmd Professions Code,andmyliccnwis
y in full force rete a cd.
5 a Linen cls e Lic.« 7! REROOF W/SHINGLES
ON
n� Dam (l/xs Yior Comncmr v AS M„ <�2 CONTRACTOR: WESTERN N nnnn��[[++TR UCTION
ARCHITECTSs shalDECLARAcords w iw.� F1
�i 1 unMmanJ my phos shell be mud a public records i^ a LEE Fp
s.s.0 LxenssdPmfcssianel
OWNER-BUILDER DECLARATION
3 i y I bertby affirm on 1 1. exempt from nbe Coosracmfs License Law for the
pO which
following reason. ecotton E)7str t.alter. and vefdcmuli Code:Any tiny or county 5 —�
$iei which its a..a permit to construct.aloe improve,h rebuff,or repair any atrupmm „J
that he its issuance,also pursuant
to[be he eppli s of for sucContoarmis a Gic s sLaw(usemem
< (Comma(Commencing
wait puacibm7 t0)of Division
of Ne Consruofallanss loons CodmrY Sq.Ft. Floor Area VaIU
flat
he is eng with Sepia m,and of basis
3 or the,Busaged ess andexempt Proon.Any
vi Codc)of �L 10 0 0
.. Nas Section
is 31.5 b Nem from and or aura for Ne alleged exemption.Any lineation of
6'at.. thein byany applicant forsaminosubjccutheeppl¢anuo•civil Penalty pf APN Number ane Type
not more than Erc handed doom($soB). P Y YP
❑I,u twneroftbe property,or my employcn with wsgcau their sole compensstlnn, 37514016 . 00
will do the work,and the[aYa9a d is not intended or offered foreale(See.7744,Business
and Profession Codc:The Conuumr's License Law data not apply an an owner of Required Inspections
property who Wlldaor I.,..thereon,end whodocssuchwarthimselfor through his
own employees,provided Nan such Improvements ere not intended ororfered forssle.If.
however,Ne building or improvement is mid within one year of completion.Ne owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale I
❑1,as owuer of this property,am exclusively contracting with licensed...,.so
consumer he pmject(Sec.7W4,Business and Professions Code)The Courageous Li. .
cense law docs not apply to an owner of property who Wilda or improves sbemon,and
who contracts for such pmjccu with a contractor(t)licensed pursuant to the Contractor's
License Law.
❑I am cramp,under See. Bk P C fu this ninon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afMn under Penalty of perjury one of she fallowing dalmsions:
1 have and will maintain•Conflicts,of Consent toselBlnsure for Worker's Compton.
7C311y",
on,u provided for by Section 37M of the Labor Code.for Ne Performance of the
k for which this permft is issued.
1 have end will maintatn Worker's Compensation Insunnce,n acquired by See inn
M of the laborCode,for the Performance of Ne work for which Nis Permit is issued.
Worker's Compensatio Insurance/carrier and Policy number am; orier: 7AAW Policy No.:�J Y-�+
CERTIFICATE OF EMEMPDON FROM WORKERS'
COMPENSATION INSURANCE
('ITh sectio recd not hecomplered if the permin Is for ane hundred dollen(SIM)
or less.)
1 certify that in the Performance of the work for which this Permit is issued,I shall not
employ any person in any menoer so as to become subject o the Workers'Compensation
Laws of 6ltfomia.Dam
Applicant
NOTICE TO APPLICANT.If,after making Nle Certificate of Exemption,you should
become subject to the Worker's Compensation provisime,or the Labor Code,you must
.JO forthwith comply with such provisions or this Permit shall be deemed revoked.
'Z N CONSTRUCTION LENDING AGENCY
{~ I hereby affirm Nn Nem is a construction lending agency l'nr the Performance or
6i
be work fur which this Permit b issued(Sec.3(19),Civ.C.)
Q Lender's Were
lL
lL z Lender's Address
U C) 1 ttnify that I have rod this application and sum that she said.formulated is
11. H correct.I agree in comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorise mpresencidws of this ity to enter upon the
N V) above-ment
ioned d nt.Cos rue inspection Purposes. e�///
(We)egoe m save,indemnify and keep harmless the City of Ci pcnirm against l ! lwsr \Jell/Y/IN/ �-
,F.� N in consequence f the granting
and of this a which may in any way earvc against aid City
U z in consequence of the graining of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date - L L�
SOURCE REGULATIONS.
Re-roofs
Signature or AppliceHAZARDO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy t applicant or fount ipal Co occupant or handle Health as material
u deleted by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.illicale,Section 25532(a)'f
Yes [�Na All roofs shall be inspected prior to any roofing material being installed.
❑
7dwsWill she applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haominous air comeminanu n defined by Ne Bey Arta Air Quality Menagcmcmall new materials for inspection.
❑Yea 10No
I have mail Ibe statement,materials requirements under Chapter 6.95 or the cabins-
calN@SatclyCodc,sectionsnN)5,25537 and 25534.1 undcrsond then if the Wildingnot currently ham a tenam,Nan fn h my ecsponsihility to nod ly thc occurred of themmcnu which must Wm ed Fdono issuance ars Cedifinete ofOccupancy. IgnalUre Of Apphca0t Date
r or ammo axed agent Data All roof coverings to be Class "B" or better
x
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT # �S�„�/�13
o �ciS� �/c✓e 15`i' ;Z>,—. CJ`s
OWNER'S NAME: PHONE # ¢o00_Py/ ,00
GENERAL CONTRACTOR: yt/ .�iLJoc e..r tc FAX#
I am not using any subcontractors: S—
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
. Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
UV Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development Department
Building Division
til City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY C•F Fax: (408)777-3333
UPEkTINO
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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled
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: C�e1 I G'`r e
Job Site Address: /D�Qr /l/Loi
Roofing Company Name: ���STcriV/I��c��i r�n✓Tisc c7 rul /h�
Applicant's Signature: Date: 112
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
II-- RER®®I o S�—v o (2
CUPERTINO PERMIT APPLICATION FORM
APN # /
Date: S/-
Building Address: /
d t Qe t �f _ G C/ i/bU l/Q O
Owner's Name: Phone#:
/ CXe n 1
Contractor: Phone : License#: -7 X 97 6'
Contact: Phone#: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑/ Built-Up roof
❑ Asphalt Shingles fY Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
V/ Other(Specify) 71/g pq e ) ❑ Other(Specify)
Number of existing coverings oO S�f ❑ Provide I.C.B.O.Report#
Q� To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: EV
Job Description:
Teavo ?,f"/S>5' Cn�i!'.--A 7% foo s/A.�e (S� ,
Residential � Commercial ❑
Fire Zone: Yes ❑ No Confirmed with PlanningD_ept. if
there are any restrictions: u
Cost of Project: Type of Construction: Occupancy group:
//omc9
Qty. if
A lic ble Fee ID Fee Description Fee Group
UIBPERMFEE 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