03100162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT `',"CONTRAC bR TNTORMATION:, .
BUILDING ADDRESS: J. TOLENTINO PERMITNOO 3100162
.31 0 PALM A17
OWNER'S NAME: 284 BURNING TREE DR PERMIT ISSUE DATE
VAN BLOMMESTEIN 22 2003
NE: (408) 578-4141 SANITARY NO. CONTROL NO.
ARCHnECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!00 LICENSED ONDed under provisions
DECLARATION
(u Ihereby i..79affirmNalIamBthcruanderpmwamneof,Coda. 9(commencing eis Job Description
with Secoion7 )of Division]of the Rusinesn3tid Profession Cade,end my license is
+ee imm�man dart `� �7 � REROOF
��? Liceme=�Lic.N
s=p Dam Comm t
A Call Muss D[C 'TION y
f I u denonJ my plans shall he aseJ as pdM1lic records V
'w� Licensed Professional
in OWNER-BUILDER DECLARATION
<F 1 hereby affirm that I am exempt from Ne Contractor's License Law for the
0 o following mason.(Section 7031.5,Business and Professions Code:Any city or county
en
m which requires a permit to construct,abet,improve,demolish,or repair any structure $1500
prior mats issuance,also acquires the applicant for such permit to rile a signed statement
that be is licensed punuenttothe provisions ofNeContractors License Law(Chapter 9 Sq.Ft. Floor Area Valuation
;:c'I- (commencing with Section 71g1(y)ofDivision 3ofthe Business and Profession Code)or 35704023 . 00
tk hat is csempt departure and the basis for the alleged esempuon.Any violation of
Section 7031.5 by airy applicant fon permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mon Nan five hundred dollar(5500). P y yp
o I.a owner of the property,or my cmployca with wages a their sole compensation,
will do the work,and th madvani.not intended or offered rat (SCe.1t..Ew seaE
and Professions Code:The Conuaclor's Licema law does not apply a an owner of Required:I�t SpCCII00S
propeny who Wilds or improvesNereon,and whodoes such work himselfar throughhisPrya_
I(r'�own cmployca,provided that man improvements arenm intendedoroReredforale.IL5 �however,the building or improvement is mid within one ear of completion,theOwren1builder will have de Eurdm of proving Na he did nm build or improv far purpose of
able.).
I,es owner of Nc property,em exclusively contracting with licensed Contr ct rs to comwct the project(Sec.70 ,Basmoss and Profession Code:)The Conaacmts Li.
came Law does not apply he an owner of property who India or improves Hereon,and •ad'
who concocts for such projects with a contractor(s)licensed pursuant in the Conemlori
License Law.
❑I am exempt under See ,B k PC fm this noon
Owner Data
73010WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ore of dre following declan0on:
1 haw and will maintain a Certificate of Consent to selblmure for Worke's Camper.
0
on,as provided for by Section 3700 of the Labor Code,for the performance of the
k for which this permit is issued.
I haw and will maintain Worker's Compensation Insurance,as acquired by Section
of Ne Labor Code.far the performance of the work for which this permit is issued.
Worker oiania cecarticr endPoliyaier. V ZA _
CERTIFICATE OF EKE ORFltOM WORK ERS'
COMPENSATION INSU RANCE
(Thu section need not he Compared if the permit is fm arc hundred dollen(S 100)
or less.)
1 certify Han in He perfom ane of the..,it far which this permit is issued.I shall not
employ any permit in any manner an as to become subject to the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
bttome subject to the Workers Compensation provisions of the Labor Code.you must
�O forthwith comply with such provisions or this permit hall be deemed invoked.
ti iZ) CONMCf10NLENDING AGENCY
I hereby arm that Here its conwninn lending geuy I'nr the performance of
Ya the work for which this permit is issued(Sec.3097,Civ.G
s7 0 Leader'sName
7 z Lenader's Addreu
Q 1 certify that 1 haw read this application and sue that the above information is
y F emzen.1 agree to comply with all city and county ordinances and soon laws relating to
�U building construction,and hereby authorize mpresematiwa of this ity to enter upon He
W above-mentioned property for inamcdon purposes.
gL (We)agree to sew,indemnify and Imp harmless the City of Cupertino against
q liabilities,judgments,Cosa and expenses which may in my way accrue against mid City
JZ in consequence of the Starting of this permit.
APPLICANT UNDERSTAN S AND WILL COMPLY WTTH�ALL ON-POINT Issued by: Dat
SOURCE RE U A ON
Re-roofs
Ignatuze of Appiica ontnctor em
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant state or handle hazardous material
as dofmcd by do Cumnino Municipal Code,Chapter 9.11,and the Health and Safety
.on,Serum 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yea t�No
Will the applicant or future building occupant use equipment or devices whish If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air cnnomimnp as defined by the Bay Arca Air Quality Management all new materials for mspe tion.
oleo?
❑Yen �No
/
I have mad the hate ms maarials requirements under Chapter 6.95 of the Cali fro, q
ria Health @Safety Code,Soedoa 255115,25533 and 25534,1 undersand Han if He building
duce not'unmet y h.,?;at 4 't u my responsibility m mul'y the mcu ant nr the
requirements whi�mus a et nOn mcc-fa Ccnifcetfof flop;ol'�y. 5`I fApplicanl Date to
! —� �7 D
Ownceo Ihorizcda m ate All roof coverings to be Class°$°Of better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEkTINO
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: T ll- (M.A Via--N gI p�0
Job Site Address: I `£ �� /4 ,'A4 V D 5k
Roofing Company e: b ,E N iwb W-0-a /
Applicant's Signa Date: °3
• Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
1
CITY OF CUPERTINO 6-31, 0 , 162--
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
3S' o ) ;-, 3 W �3
Building Address: �
Own 's Name: Phone#: _J 9
Y-144 04 N T3ld W kW4-575 GN 1`
Contra tor: Phone#: License#:
ti �1Aj 6, 46&F-S7 +14( 57 8-"6 Z 7
Con act: Phone k Cupertino Business License#:
P'N 4ts ir- ;28 1-
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles X 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 Polic : ❑
Job Description: -11.,5- a x 36 ' Al, fd Y tAd/�VWV'- R-0 3 6 �Al2 E1 k—
u elQ ex rS� Cos1 au
Residential 15 Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plan ' ep . 'f
there are an rest ' ions: LJ
Cost IV
Pro ect- Type of c o Occupancy gr p•
Qty
-
App
A 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
•
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