04010067CITY OF CUPERTINO
BUILDING DIVISION PERMIT
I14FORMATJON r
uCON.��C,T}OR
BUILDING ADDRESS:
1-0071 PACT21CA. DR
PERMIT N0.04010067
WNER'S NAME: -
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
I hereby affirm that I am licensed a provisions of Chapter 9 (commencing
with Scc'an7q%1)uf Diviaion3of the Busingi(and P�c�siOs enypy hemseis
in full fated cffec / • L/
lS
REROOF
CONTRACTOR: MBROWN CONSTRUCTION, INC
ARCHITECTS DGCLA_ TIO ,!. $$ sA
I untlermand my plans shall he used as (ruAlic rccoNs �` s
Licensed Profession.(
DECLARATION
Oat
I am the Contractor'sxCod License Law for the
1 hereby .('firm that 11. exempt
srum
mason. (Section ]831.; Businessmpr and ie Cmle: Any city or county
demolish,
de
which improve, demolish.
requires a pcmit alter, ire repair any structustatement
oeirquire
whichitsissuance,
file
prior ha its i eased p Ju my. the the for such permlr m f Ie License signed narement
re the for such
thathe rothc (ChapterCode)
Sq. Ft. Floor Area
Valuat 38050
or
(commencing with Section 701)(a) of Division3 of theegedexeandon.An vi Codc)or
menccgwith Section of Division 3 of the BuacmtinProfessions
Nat he u exempt therefrom and dm buts for the alleged exemption. Any violation of
APN Number
Occupancy Type
F y yp
Section ]031.5 by any applicant for a permikaubjects Ne applicant o a civil penalty of
not more than five hundred dollars(S50o1.
C has owner of the preperty, or my employees with w.ges as their a to compenutinn,
36929002.00
e
Required IDSA■3l3liF■!
■
intended
will do did,work.and the aheContra not intended Law offered
ntapply 7044, Business
and Professions Code; The slum is not
Law does not (Sec to an owner or
property who builds or improves Hereon, and who does such workhimulf orthmugh his
■HALM
own employees. provided that such improvements arc not intended oroRered Pursue. If.
however. He building or improvement is sold within one year of completion, Ne owner.
builder will have the burden o(pmving Nat he did not build or improve for purpose of
JA
JAN2004
sak.).
0 1, as owner of rhe property, me uelusively coneracing with licensed contractors to
construct Ne project (Sec.](M4, Business and Professions Coda) The Contractor's Li-
_ BUILDING
chose Law docs not apply to a owner of property who builds or improves Merton, and
who contracts for Such projects with a contractor(a) licensed pursuant o Rod Contractor's
Lumnse Taw.
❑ I am exempt under Sec. ,B& P C for this reason
,am, Date
-
WORKER'S COMPENSATION DECLARATION
1 hereby afford under realty of perjury one of the following declarations:
I have and will maintain a Certificate or Consent to self -insure for Worker's Cooper.
sated, as provided for by Section 3700 of He labor Code, for the performance of the
work for which His permit is issued.
0 1 have and wit maintain Worker's Compensation Insurance, as n lifted by Section
37W of Ne Len Cod, for Ne performance of Ne work for which this permit is issued.
'
Workefs n satian Insurance carrier end polioun�ra -7(
-
C.
Ca Policy NNqO� '
CE TIFICATEOF F'RAN WORKERS'
COMPENSATION INSURANCE
�+q�OMPENSATION
seetion and nal he completed if the permit is fnr one hundred dollars (SIIXB
'
or lcsa)
1 certify Nat in the per(ornam. of He work fnr which this permit is issued, I shell net
employ any pecan in any mannersn as no become subject o the Workers' Compemation
Laws.f California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Comficare of Exemption, you should
became subject to the Worker's Compnuation provisions of the labor Codc, you must
forthwith comply with such previsions or this permit hall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I thereby affirm Hat there is a constructed lending agency for Nc performance of
'
the work for which this permit Is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have mad Nis application and sum the, He above information in
correct. l agree to comply with all city and county ordinances and sate laws relating to
building conswction, and hereby notarise mpmsematives.f this city to enter upon the
above-mentionedC)fire property for inspection purposes.
(We) agree to save, indemnify and kith harmless duew City of Cupertino id City
and expenses which may in.nyway eccue against mid City
egjnce
a.
r
inof the of this
Aeonxyucnec of the griming of this permit.
/
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT
Issued by: Date
SOURC CATIONS.
Re -roofs
-
Type of Roof
huurc of ApplicenUC ar y� em
re
If A OUS MATERIALS DISCLOSbRE
Willtheappive.n rF.t.buildingu¢upanl stomorhandlchamdousmaMdaI
as defined by the Cupertino Municipal, Code. Chapter 9.12. and the Health and Safety
de,SecYen 25532(a)?0tics Nu
All roofs shall be inspected prior to any roofing material being installed.
" If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or m building occupant art equipment dr devices which
it her tlous air conmmin nu as defined by He Bay Arca Air Quality Managcmem
all new materials for inspection.
sett]
C Yes
_ I have mad der haaardo s 3Rrials requirements under Chepmr 6.95 of the Califon
nisHc.W&SafcryCode,Sdcdi.25505,25533and25534.1undcnwdhaif Nc building
- -
Jou not curtently pew a ¢dank Net it iS my msponsihility io notify the rccu ant of ur
%- /
rcyuiremcnuwi stbemetprior toin Or. ccmricdseof .Pl
i�
Signature Applicant ''- Date
of
I roof coverings to be Class "B" or better
owner
d avmerius asenr D/
j Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
%CITY OF Fax: (408) 777-3333
UPEI�TINO
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
IMPORTANT:
1. Flat roofs must have a minimum of " 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 withtheabove stated policy on re -roofing.
Homeowner's Name: Y �S t t K� ¢, �(P+ � ` /t t1p D C4 (VL 9
Job Site Address: Z�� f O C\ t I I C V ��rcYl i� o CA 61l SO j Y
Roofing Company Name:
A plicanYs Signature:
C�l/�6WDCJV
Greg teel
Building Official
('o -11-0y)
Revised 1/30/03 '
Printed on Recycled Paper
Date: 117 / 0 7
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 " 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 withtheabove stated policy on re -roofing.
Homeowner's Name: Y �S t t K� ¢, �(P+ � ` /t t1p D C4 (VL 9
Job Site Address: Z�� f O C\ t I I C V ��rcYl i� o CA 61l SO j Y
Roofing Company Name:
A plicanYs Signature:
C�l/�6WDCJV
Greg teel
Building Official
('o -11-0y)
Revised 1/30/03 '
Printed on Recycled Paper
Date: 117 / 0 7
IL
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Fj
cin of
CUPERTINO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN # n / U �_
.
Date: -d
j D
BENERGY
Building AdJ_rbO —7
I Cc Gfi=i L ,
Owner's Name:
lS �-�v► e 4 (� L� �) l mat
Phone #:
gcl7 ? • 2S� '� (0`Z%
ConPhone #: 4512 � 60
1v 4� � l C U_L
Lice [ .
a 22
esvi3 ►�t� c . l2� o
BUILDING
Con t:Phon #:
s Ircr.� cv� -10- U (, 0 )
Cupertino Business License #:
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)
N mber. 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:
a til Yq'
ewtovc. co
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project- Typ of Corlstructi� Occupancy group: S�
—Y(p O "_
Qty. if
Annlicdblet ) Fee m
Fer ilecrrintinn
V., (:r
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