04070003 CITYOF CUPERTINO " ¢ 'F
BUILDING DIVISION PERMIT c0N4 it-Vo .XNI+!f�[tMa1' .'ION
'BUILDING ADDRSTERLING GENERAL CONSTRUCT: PEAA4
TIT"
%4070003
OWNER'S NAME: PERMIT ISSUE DATE
Alk ERWEST ROBLE
ONE: SANITARY N0. CONTROL NO.
(408) 266-2036
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOZ LICENSED CONTRACTOR'S DECLARATIONO O O
I hereby o frm that 1 am licensed under provisions m Chapmr 9(comme.ming lob Description
;� withSwd�n,]IXy])of Divmion 3af dm Husines ofcaalons Code,end mylironse is
Daull force.F�rGfrc e ? REROOF
LicenuC Lie.g� �G V�
lq- ARCHTfELTS DECLTi�pTIn'
WU yatlen )ray/�Af he used as pmcnrJs
o r' Licc ed Pns e A ®e®� OPit
OWNER-BUILDER DECLARATION p
.� 1 wrathy affirm that am exempt from the Contncmfa License Law for the
p O following reason.(Section 7031.5,Business and Profession Cade:Any city ar county
E:$9 which acquires a permit to construct,alter,improve,demolish,or repair any structure Vcnnn
riyprior in its issuance.also mquirea she applicant(orsuch permit to file a signed sntemenl
1- < that he is licensed purtmattothe provisiomafBwConnector's Useave Law(Chapter 9 Sq. Ft.Floor Area Valuation
y+ Q (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he Is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant o a civil penalty of 3 51104310"i circ 0 Occupancy Type
not mom Nan five hundred dollen(5500).
❑t.as owner of the property,w my employees wide wages as their sole compensation,
will do Ne work,and Ban swcmm is an intended or offered for sale(Sec.7044,Business
and Profess..Code:The connectors License Law does not apply In an owner of Required Inspections
pmpeny who buildsor improves thereon,and whodurnsuch work himselfor through his -
awn employers,provided Nat such improvements are not intended or offered for sale.if.
however,the building or improvement is sold within one year of completion.to owner.
builder will have Ne burden of proving that he did not build or improve for purpose or . .
sale.),
❑I.as owner of the property,am exclusively contracting wit licensed smseserors to
construct Be project(Sec.7044,Business and Pronnamn Code:)The Contractor's Li
cense law does not apply in an owner of property who builds or improves thereon,and
who contracts for such projects wish a conuacmns)licensed pursue.,in the Contractor's
License Law.
0 1 am exempt under Sec. ,B&P C far this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affnw under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to sel6insum for Worker's Compere
sedan,as provided for by Section 3700 of the labor Code.for the performance of she
work for which this permit is wand.
❑I have and will maintain Worker's Compensation Insunna,es required by Section
37W of NC Labor Code.for the performance of she work for which this permit is issued. -
My Worker's Compensation Insurance carrier and Policy number am:
at. Popo': z •
CERTIFICATEF XEMPfION FROM WOR C•RS
COh SADON INSURANCE
(Thissection wed not be completed!ilk permit is fmronehundmd dollars($1001 '
or less.)
1 artify that in the perfowance of the work for which this permit is issued,l shall not
employ any person in any manner m as in become subject to rhe Wmrkms'Comprnsatlmn .
Laws of California.Dam
Applicant
NOTICE TO APPLICAN7:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Cocke,you must
O foMwith comply with such previsions or this permit shall w deemed revoked.
.Zi te( CONSTRUCTION LENDING AGENCY
r
[—t 1 hereby Mo.Nat them is a construction lending agency for the performance of
y'.� dm work for which to,permit Is issued(Sec.3097,Civ.C.)
QLender's Name
r7 z Lender's Address
V Q I certify Nal I have and this application and sum that the shove information is
(—' correct.I agree 0 comply with all city and county ordinances and state laws mlating to �—
OU building construction.and hereby authodm mpurematives of this city in enter upon the
C17 ahow-marlamed property for inspection purposes.
(~y (We)agree to save,indemnify and keep harmless the City of Cupertino against
fJ) liabilities,judgments.casts and expenses which may in any way some against said City
fJ z in consequence of the granting of this permit.
APPLICANT UNDERSJAJJDS AND WILL COMPLY WITH LL NON-POINT Issued by: Date
SOURCE REGULATI S. flqt,
Re-roofs
.gnat of ApplicardConrraclor Dom
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will sm applicant or future building occupant nm.ethanol.hmardous material
sa&flood by the Caronino Municipal Codc.Chapter 9.12,and the Health end Safety
Code.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
r7 Y.. K.
Will the applicant or(serum building aaupant use equipment or Jcvices which
If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air cmumaiwats as defined by the Bay Area Air Quality Management all new materials form tion.
Dixtria? '
❑Yes tau✓
I have mad the hannims materials requirements underOmpmr 6.95 of the Calimr, /� n
nia Health&SafelyCow,Sections 25505,25533 and 25534.1 understand that if the building
J mol-currently haw a mass,,unit it is my rea mosibilisy in notify ft occupant of use
quimmeni '.bred etpdo Wuanceef rdfcamofOccupancy. 1 o Applicant ate
amhonzed agent Ef.to All roof coverings to be Class"B"or better
Community Development Department
Building Division
City of Cupertino
' 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF
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) 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 J0 stated policy on re-roofing.
-
Homeowner's Name: EV' Ili _e I� LJ
/l2 - (' L
Job Site Address: �S �'1 I . V Q/J /
Roofing Company Name: CQ'L.
A plicant s Signa r • Date 101
• Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
-CUPEkTINO PERMIT APPLICATION FORM
APN# Datos6q4_026 00 l r
Building Address:
//R l,- MT
Owner's Name: hone#:
tit L � � 'I �b8- 3�3Q1
Contractor: Phone#: icense#:
/08 2LG -.g03t 8
Contact: Phone : Cupertino Business License#:
W'8 � 2-7-iz 3S 2 2 F 22
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
tlY Wood Shakes W- Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ 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: �_ n
J CIA yt- ,
Residential Cormh4cial ❑ .
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: E
Cost of Project: Type of Construction: Occupancy group:
Qty
A c le Fee ID Fee Description Fee Group
BPERMFEE BldgPermit 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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