03080127 CITY OF CUPERTINO
BUILDING DIVISION PI 'MIT ReONTI2ACTORANFORMINTION
,or ADDRESS: GROMO ROOFING PERMITNo03080127
-420 MORETTI _QR _
OWNER'S NAME: 121 W WASHINGTON AVE . PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 746-2075
ARCHITECGENGINEER: BUILDING PERMIT INFO
BO ELO PLUMB MEOCH
1000LICENSED CONTRACTOR'S DECLARATION lobDescri Description
;.5 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
ZZwith Section 701KryofDivision3o(OeBusinesrand ProfessionsCode.and mylicense is PINALED
s<<O� in full force and cffe SJP7Jy REROOF
jaZ License Class Lic.X
yf� Dam Cumrena l� r�]
AR H ITECI'S DECLARATION SEP 2.2��
I
V 1 understand my plans shall he used a public records
ii Licensed Monsoonal
OWNER-BUILDER DECLARATION BUILDING
a F I hereby affirm that I am exempt fru.the Contractor's License Law for the
00 following reason.(Section 7117 t,5,Business and Pmfemimu CWC:Any city of county
1 m� which requires a Permit to coronet.sitar,improve,demolish,nr repair any structure
-¢i prior to its issuance.also requires the sent less,for such permit to E to a signed statement
that he is nttpa
licensed pursuant the mvisioof be Contractors Law w(Chapter9 Sq. Ft. Floor Area Valuation
lice
e'c (commencing with section 7")of Division]of the Business and Profession Code)or
Nn he is excml4 thcmfmm and Ju bats for the alleged eamp0on.Any violation of 37516001 . 00
Section 7071.5 by any applicant for a permit subjects On applicant o a civil penalty of APN Number Occupancy Type
ort more Nan If.hundred dollars($500). /
❑ I.as owner of the proper,or my employees with wages a their sole compensation.
will do the work.and be snctum is not intandcd or offend foraale(Sec.70s4,Business 3 05 _ PAMLi'
and ProfeWnna Code:Tire ConbSmrs License Law sees not apply m an owner or Required Inspections/
property who builds o improves Nerrnn,and who doeaauch work himselfor Jou{h his 307 - INSULATION
own employees,provided Oat such improvements art not intended oroRerW for We.If. 601 — ROOF TEAR OFF
however,be building or improvement Is sold within rete year of completion.be owner-
buliderwillhaw ftburden of proving,but he did not Wild or improve for purpose of 602 - ROOF PLYWOOD NA L
axle.).
❑1,as owner of the property,am exclusively convecting with licensed contractors to 6 03 - ROOF BATTENS .
coarct the project(sec.7044,Busren..and Pndeationa codes The Corrientes Li. 604 - ROOF IN-PROGRESS
cane law docs not apply to an owner of property who builds or improve thereon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Comoro' /
Liana Law.
❑ 1 hon exempt trade,Sea .B&P C(a,Nis recon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of arjury one of be following declarations:
I have and will maintain a CeNfmConsent mm
ae of Conseno self-infur Workers Compcm
7c,
ion,a provided rot by Section 77W of be labor Code,for be performance of the
rk for which this permit is issued.
1 have and will maintain Worker;Compensation Insurance,a required by Section
W o(Ju Labor Coale,for be performance of be work for which this permit is issued.
Worker;CompensationInsurance carrier and Policy number are:
mera T.7 T/.- F1� 0 Policy No.: 2F f' // f7
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This secion need nol beeomplcied If the permit Is formic hundred dollar(5100)
less.)
1 cenify Nat in the performance of the work far which this permit is;bund.I shall ret
employ any person in any manner an as in become subject o the Wmrecri Compenaation
Laws of C.hr..in Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Com(easotion previsions of the labor Cattle,you mus,
.J O forthwith comply with such provisions or ibis permit shall he deemed mucked.
z v CONSTRUCTION LENDING AGENCY
[r Ihcmby affirm that there is a combustion lending agency for Ne periermams of
!Yid ft work for which this permit is issued,Sec.300,Civ.C.)
QLattices Name
z Lender's Address
U 1 cenify Nal 1 have read this applies,;..end neo In.,the above information ts
D. E' correct,1 agme Ire comply with all city and county ordinastcn and state laws misting to
0 building construction,and hereby authorise represcnuives of this city to tour upon the
r a shew..emiuned pmpeny for inspection purposes
(We)agree maw,indemnify and keep humlass the City of Cupcnino again,
H y liubilities,judgments,costs and expenses which may in any way acme against said City
U Z in consequenec of the gma ing of this permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ULATIONS. /
zr Re-roofs
amu of AppticanvConractot Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or rum.building oecupat sore or handle haes hens ro lerial
as de0ned by the Cuperim,Municipal Code.Chapter 9.11,and the Health and Safety
Cute,sec❑tiYrson 155510)? All roofs shall be inspected prior to any roofing material being installed.
[AJ94u
Will the
'7 If future building Occupant rex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
OL havafdrus air motamimmis a defined by,he Bay Arca Air Quality Management all new materials for inspection.
isbicl?
❑Yes �IN.
IhavefctyC mad huawoonsous 25 rialsreyuimmc55 4.[ Chapmr6.95mfthc Lidding
ria Hnith&SNctyhawaMO,tonam.that it is MY Jund155]4.1 unJcntantl Nairmsol f ft � r �l �' 2-
units nm currently how amens that it is my rnpomihility m nmil'y,h<ureupan,of the
mquiremenuwM us,W at prior toOno enma.faCe 'finuo(Occommey. SignatureofApplicant Date
�,c_ ^ P-1l' o
V
authorised agent pare All roof coverings to be Class"B" or better
t i
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY�F Telephone: (408)777-3228
OUPEkTINO 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) Ficial 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: /0 7 Z o 1-�-0 Z F T T / D 1L .
Roofing Company Name:
A plicant's Signature: ��� Date: P/Z S�D3
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO D 2-7
0REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# i - Date:
Building Ad ess:
/ y Z 0 --1 7- 1 D2 •
Owner's Name: Phone#:
yon 3GV_ O G 60
Contractor: Phone#: License#:
6-IzaI-KJ lz, Ora A.1 a- yo6) JY6- 207S" jid-3Jy
Contact: /,Phone#: Cupertino Business License#:
/O op op�f)— S- / 69
Type of Roof Covering:
Existing: Proposed:
& Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Jil� Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings 2 ❑ Provide I.C.B.O. Report#
To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
7Ai/rt - UP Vvic7- v/* V / m/ TSfL JDYf9iC r�HQ• l��i�t/f
Residential ® Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any rest ton : LJ
Cost of Project: Type of Const Occupancy gr
Gi Sym Rt - /c/aF
Qty. i
A li a le 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
2v� �