04040026 CITY OF CUPERTINOR "
BUILDING DIVISION PERMIT CIJ TRACfiOXi tN' ORMA"CTQYA'"
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BUILDING ADDRESS: CASTO ROOFING PERMIT NO.04040026014 TgniTEMBIER DR.
'
OWNER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY OL NO.
O .
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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+100
LICENSED CONTRACIOR'SDECLARATION
��ppp— uClasby lartses DNiWast loI nam3olicensedtuipndsseraprovisionsProfcdof
m Chapter
ra9nd
(cmaymlmic<nenseinlga JobDescription
with1
U A
LE
'"Dua in fail fo d 92�z REROOFDaoContractor
ARCHITECTS trpgaRATION APR 2cr 2004
mond my Plan.shell Be mad M Public«meds
io Licensed Professional BUILDING I DING
OWNER-BUILDER DECLARATION 4/ 0m rtl
f 1 hereby affirm Net 1 am attempt from the Communes License Lew for the
D O following mason.(Sudan 713I.S.Business and Professions Cade:Any city of county
$ which mquims a permit an commact,altar,impmm,demolish,or repair any strucam see
Prior w its issue=,also mquims the applicant for such Permit to rile a signed statement
`i'n that he i,liccmudp....alt.the pnvisi...ftoContractor.Li... aw(Chapter 9 Sq.Ft.Floor Area Valuation
�F$ (commencing with Section 7000)of Division 3 of the Business and Proretsions Code)or
that he is exempt Btaufmm and the basis for dm alleged exemption.My violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of 3�.pi.T.A7.....L,erO Q Occupancy Type
not mom than ftm hundred dollars($500). 0433, LL"!J 4'
❑I.aawnernt the property,or myemployws with go.as theirsala compenuBon,
will do But work end the sbuctam is unintended oroRered tarsal.(Sec.7044,Business
and Pmfessiona Code:The Conwcmr'License Law dors not apply w an owner of Required Inspections
p mpeny who buil ds a improms Btarcon.and who dal such work himself or tlemugh his
owncmploycee,provided that such improvementsare nolineended oraifered forsaba.If.
however,the building or improvement is sold within one year of completion,the owner
builder will Mm the burden of proving But he did not Wild or Improve for purpose of
sale.).
❑1,as amer of the propeny.am"elusively contracting with licensed conueclon to
construct the pmjen(Su.7044,Business and Professions Code:)The Comma; ra Li.
come law dao not apply b an owner of pmpeny who Wilde or improves thereon,and
who contacts for such projects with a canwcmr(s)licensed pursuant to the Convectors _
License Law.
❑lamettemplunderSec. ,B&PCfar Nismamn
Owner Dov
Adk WORKER'S COMPENSATION DECLARATION
I hereby torn
under pendtY of perjury one of Ne followinS declemlians:
I hem end will maintain a Ceniriata of Convent wselGinsum for Workers Compcm
sation,as provided fw by Section 3700 of the labor Code.for the Performance of the
work for which this permit is issead.
❑I ham and will maintain Worker's Compensation Insurance,m required by Section
37W of the tabor Code,for the performance of the work for which this permit is issued.
My Workers Cnmpen don In literate carne end Policy. ram:.
Cartier. a ✓IL PolNo.: Zeb�
CEAFIC— E OF EKEMPnOt4,FROM WORKERS'
COMPENSATION INSURANCE
(This section aced nut W completed if the Permit if for one hundred dollass($100)
or]a..)
1 unity that in the performance of to work for which this permit Is issued,i shall not
employ any parson in any member an as w become subject to the Workui Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificates of Exemption,you should
become subject he the Worker's Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z r~�.. CONSTRUCTION LENDING AGENCY
[-r I heuhy alters that Neu is a construction lending agency for to Performance of
bei t7
But work far which this permit is issad(Sec.3097.Civ,C.)
6iQ Lender's Name
z Lender's Address
U Q I certify that I have mad this city
and county
and sum that the above information is
U. F bumecL 1 agree to comply with all city us county ardinaef and Tum laws relating e
V building mhouadtioomd hereby audonmuivrs of this city to tour upon the
W ahovc(We)agree
property for inspectionkeeplpurposes.
In
(We)agree m taw,indemnify end kith harmless the City of Cupertino against
ry) Iiabilides,judemcnb,wooand.11 u;expenses which may in any way attest againstuid City
(„)z A APPLICANT
of the gaming of Ibis pr
�. APPLICANT UNDERSTANDS 'IL COMPLY WITH ALL NONPOINT Issued by:94a� Date
SO CE REGU
Re-roofs
signauulfu so R/Con for Data
H RDOUSMATERIALSDISCLO RE Type of Roof
Will the eppli morfuwm building ouWantatomorhardleharudous material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
,dMLCoda.s Ben zss3z(an All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or arum building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air cunmmmutas es dcMcd by the Bay Ara.Air Quality Mar,aarom all new materials for lnspe tion.
District?
❑Yes
I havcmad NehaaM smalcnalsmquimmcnvundcr Chapwr6.95ofthc Califo,-
nia Health&Solely Cade,Sccuons 8505,25533 and 25534.I understand that if the building tC//✓
dace not cur ently haw a moan 'I u my responsibility m noBl'y Bre occupant of are
requirements which mus tor, w issuance or Ccnifmata of pane Sign re A licant Date
mora a zed as I �Got.' All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aC104F
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
UPERTINO
Building Department
JOB ADD S: ORMIT # p
OWNER'S NAMIX " t+-e,,- 7$CZULC_k PHONE
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
Roofing a Sty o i v 19722. _
Septic Tank
Sheet Metal
Sheet Rock
Tile
ntractor Signature Date
p� Community Development Department
Building Division
> City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U PE kT I N O 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: �� J a UCr/ I
Job Site Address: 103o nnileryibcc ( r
'Roofing Company Name: (� �A�-s-l-�
A plicant's Signature: `�� *' `^l� e Date: �U
GregOteel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
0REROOF v CJ
CUPERTINO PERMIT APPLICATION FORM
APN# / Date:
3 3 C>y
Building Address:
Owner's Name: T Phone#:
W 00cr' J
Contractp. S 0 00 I Phon #: License#:
19380_ Id Middlefield Way
Contact: oun,alts Phone#: Cupertino Business License#:
l 1- ` Q i Q:::
Type of Roof Covering:
Existing: Proposed:
& Built-Up Roof )( Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ 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: D�
Job Description:
ct. but N n S sfem
Residential Commercial ❑
Fire Zone: s ❑"Np Confirmed with t. if
/ there are estr• tions:
C t of Project: Type of Co ru o : Occupancy grou .
r
2Y• t
li a Fee ID Fee Description Fee Group
TBUSLIC
FEE BldgPermit Fees BUILDING
GY Ener BUILDING
ICRE Seismic Fee Res BUILDING
ICOM Seismic Commercial BUILDING
CHK Plan Check Fee BUILDING
Business License BUILDING