03060104 CITY OF CUPERTINO
BUILDING DIVISION PERMIT v£CpNTTtACTQRTN 'OtMATIgN
BUIMIND ADDRESS: LOS GATOS ROOFING PERMIT"°03060104
OWNER'S NAME: 1771 SMITH AVE. P°" R713/2003
NE: (408) 298-9399 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEM: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
o o LICENSED CONTRACTOR'S DECLARATION
1 Wreby ammo that 1 am licensed ander provision,of Chapter 9(commencing Job DescriptionB
I'
Sermon 7Wft.f Dwislon 3 of mm Recirculated Profesima s Cede.and my license is Ey(�l1{�r.xkp
a Lie, force ab act,,. Lic.x lFtl 67 Q�J REROOF
y,? Liccna CIS ( Con1sc — -
Iq- Dam v ARCHITECTS DBOLARATION x J II ft�I7
! 1 uMcnund my plant hall W used as public accord 2 3 2003
)f
it aLicensed Professional
gy OWNER-BUILDER DECLARATION
iuBUILDING
2�I 1 hereby affirm that am exempt from an
m the Conuofs License law for the
0 o follnwing moon.(Section 703 1.5,Business and Professions Code:Any city or county
5$ which require a permit to comm uct,ober.improve.demolish,ar ural,my structure
.Zi prior to its issuance,alto requirc,the applicant for such Permit to rile a signed su¢mem
€<
that he is licensed pursuant in the Provisions of OneComracion.License Law(Chapter 9 Sq.Ft.Floor Area $13N§1pgtion
%;RC (commencing with Section 7000)of Division 3 of the Becomes and Profruians Code)or
that M Is exempt therefrom and the bus For the alleged euanWom My violation of
Section 7031.5 by any applicant far a permit subjects the applicant W a civil penalty of 3 ARM 9Offi6er 0 0 Occupancy Type
not mare Nu fivehundred dollars(5500). '
❑1,u owner of the property,many employee with wgea as Weir sole compensation,
willdo WewarkaMtheswclurhnofinunddmaRemdforsWe(Sm.70 .Buuneu J U b - RReei� dln5 actions
end Pacification.Code The Canatchni License Law does not apply m an owner of 307 INSULARea p
property who build or ime provIhemon.and who doeasuch wmk himself ser through his
own employ,e,provided thatsuch improvements was not in¢ndedmoRered fmals.If. 601 — ROOF TEAR OFF
bowever,the building or improvement is veld within one year of completion,We owner.
builder tat he did not Wild or improve far purpose of 602 - ROOF PLYWOOD NAIL
ala.1. 603 — ROOF BATTENS
❑I,an owner of the Property,am exclusively commucting with licensed contractors to 604 - ROOF I N-PROGRE S S
wutact the project(Sec.70th,Bulnfes
ess and Professions Code:)The ContracWb L6
cave law Baca not apply m an owner of property who Wild or improv themon,and
who contracts for mch pmjec0 with acamractuKs)liceued pursuant m the Commutes '
License Law.
❑I am exempt under Sm. .B k P C(m thismason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby,Man under penalty of perjury aro at the following leclanlimu:
I lave and will armada aCxr irtcau of Consent to self-iuuu far Wari Cooper.
afion,as provided for by Smlon 37W of the labor Code,for the Performance of she
work for which this Permit is named.
❑I ban and will chairman Workefs Compensation Insurance,m required by Section
3700 of the la W,Cad,far IW pertormana of the wart fmwhieh this pennil is Lome.
My Werke/s CnmPeu t Ica nm[artier eP`d Pol'iry number art:
Ca of .sem an n7, ',Wac 03
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fNisactinn need not W completed If eta pmmil is formic Womed dolt..(SIM)
ar lase.
I certify that in the perfmmamc or We work for which this mbMt is issued.l shall not
employ any person In any manner an u in become subjecum the Wmken'CmrPenatmn
Laws of California.Data
Applicator
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
Wmme subject to the Worker's Comrctuauon previsions of the lahnr Code,you mut
O forthwith comply with such pro isinu or this permit shall be deemed examined.
Z► CONSTRUCTION LENDING AGENCY
1 hereby aEirm Nat then is,muwction trading agency fmtM perfannarwe of
Cd 7 the wok for which Wu permit t.Wmd(See.3097,Co.C.)
QLcndch Name
7 z Lcndfs Address
J Q 1 really Wu 1 lave read this appliaarimn and sum and IW stave InfmmxWn is
S.F comem I ague to comply with all city and county ordinances and sum laws relating to
0U building convection,and hereby aummin representatives of this city in rotes upon the
N above-menliuned property for Inspection purposes.
y (We)agmeto ave,indemnify antkith harmless theyacof Cupcnst id City
y inconsectmce of the granting
ofthis Permit. may in anywayerne against aid City
J 7 in consegmntt of We ynming of Wis Ikrm't.
C APPLICANT UNDERSTAN ND w COMPLY WITH ALL N N-POINT Issued by: Date
sOURCE RE )N y
6/�3�63 Re-roofs
SignaturoodApplicart/Contai Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will etc applicant or future building excup im alore or handle hoardous mmcnal
as defined by the Caperton Municipal CMe,ChWter 9.12.and the Health and Safety
Me.sm,anz5saz(.>T All roofs shall be inspected prior to any roofing material being installed.
❑Ycm 9fNu
Will he applicant or futurebanding o aP.nl as equipment at d cewhich If a roof is installed without first.obtaining an inspection,I agree to remove
it hexamine air contaminants as defined by We Bay Arta Air Quality Management all new materials for inspection.
is ricR
❑Y. Nu
Iban&Sftthehoaalems 2550als5533amcnu34.1 r Chapter 6,95understand
ride Glding
ria HcUthkSaferyCode,Sections 25705,23573 aM 75534.1 undersand thmiflM Wilding
does;not camently hese a mums.that i my resp ibility m notify doe Attu ant of b
requirements which metp' maapG aCcnifrcwamofotaccu ` Signature of Applicant Date
Owner or authorxed agent /A �� Oa / All roof coverings to be Class "B"or better
Building Division
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: (408)777-3228
1 F= (408)777-3333
CUPEkTINO
Building Department
Subject: Reroofing policy for the City of Cupertino.
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufactures specifications on reroofing.
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 reroofing 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) Preinspection 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 that the
proper City inspection can be performed.
IMPORTANT:
1. Flat roofs must have a minimum of V"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 of inspection.
We understand the above policy on reroofing and will comply with this policy.
Homeowners Name: S+v- e b a w e r
Address: 101(0 q Qa E {��•
reroofing Company Name: Los Os o a Pi n
Applicants Signature: t:�?Ll Date:
' Joe Antonucci
(Chief Building Official)
6/25/01
Ge CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# ZIU
32( -39 ate: v
Building Address:
219 <0 9 Oakole/l Pl.
Owner's Name: Phone#:
Stofkl e bower- ypg 253-&4I76
Contractor: Phone: $ License#: goo-707
Ls filet-+o g (� 0 a
Contac Phone#: Cupertino Business License#:
71" a c�onr g 399 23�f S
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑Q Asphalt Shingles >i Asphalt Shingles
f" Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) *A Other(Specify) 5 30'6 r9el t
Number of existing coverings _ ❑ Provide I.C.B.O.Report#
)t To be Removed 'JL Provide Mfgr. Installation Specs. sa `o�-
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: p� , _ j q A� �� TG
Residential 9( 11�+� Commercial ❑
Fire Zone: Yes ❑ No ;g Confirmed with Planning Dept. if
there are an restrictions: .LJ
Cost of Project: Type of Const tion: Occupancy grou
13,000 — teemoo
Qty. if
A lic e Fee ID Fee Description Fee Group
BPERMFEE Bld Permit Fees BUILDING
BENERGY Enprav BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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