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CITY OF CUPERTINO
R�INFORMATION
BUILDING DIVISION PERMIT
.CO1PRACT�O
BUILDING ADDRESS:
COSMOS ROOFING
PERMIT N903050033
OWNER'S NAME:
1901 OLD MIDDLEFIELD .WY
"Tn8/2003
�I JOHN P AND YIT-T-AN
ONE:
(415) 493-6373
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under povisians of Chapter 9 (Commencing
with Section 7MO o(Division 3 of use Business end Professhsv Code. and my license is
F I ISI A► L E
aGd �
REROOF
Lie.Couis
Licese Inst or _
0 8 2003
ARCHITECT'S DECLARATION'MAY
1 undersand my plans %hall be, used u public records
BUILDING
Licensed Pridemional
OWNER -BUILDER DECLARATION
I hereby .(ince that 11. exempt from the Contractor's License law for my
Cm)c: Any tiny or county
following modem. (Semite )o I.S, Business and m
d emum
which mquis improve demolish, nr any wueum
a permit In wnstmm, tlor, nt
for m,
e a sig
prior w its issuenec, also mquims Ne- applicant for wch permit to rile a signet suomcm
u
of lbe Comnutar's License Law (Chapter 9
Sq. Ft. Floor Area
$6V3T tion
that he is licensed pursuant to the prevision
(commencing with Section ]000) of Division 3 of the Business and Professions Code) or
Net he is exempt Acmfrom and the huis for the alleged exemption. Any violation of
3 er0 0
Occupancy Type
for a wbket, the applicant in acivil penalty of
any applicant
.Bohm oro thou fibvu dollars
popcn'tdo myemployen withwagvuurei(cele cW.Business
❑ Ido
-}pie fired Inspections
p
will do Ne work, and Neawcture is not intended or oRerod for sale (Sec. ]014, Business
,work. and
and Professions Code: The Comeacmrs Liave Lawn nm m doapply an owner of
himself through his
307 - INSULA 1 I V N
property who builds or improves demon. and who does such work or
Own employees. provided thatsuchimprovements are not mounded ororterW toruli If.
601 - ROOF TEAR OFF
however. the building or improvement is sold within one year of completion, the owner.
Wild., woe have the wrden of moving that he did Trot wild Or improve for purpose of
602 — ROOF PLYWOOD NAIL
.1e.1.
603 - ROOF BATTENS
❑ h as owner of the propcn, am exclusively connecting with licensed conumctots no
604 - ROOF IN -PROGRESS
construct the project (Sec 7041, Business and Professions Cade:) The Conuamofs Li.
cove law docs not apply to an owner of property who wilds or improves Nercon, and
who Contracts for such polem with A contrutons) licensed Pursuant in the COM MIO. s
License Law.
❑ 1 an cacmpl under Sec. . B & P C far this moon
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under perod y of perjury one of the following decHnuov:
'
I have and will mainuin a Cenifinm of Covent orselGivum for WorkefsCompcn-
smion. in provided for by Section 37W or the labor Code, for the performance of do
work for which this permit is issued.
I brom and will mainuin Woodus Compevatian Insurance, as required by Section
39M of the Labor Code, for the performance of the weak for which this permit is issued.
My Worker's CQMI Insurance Cartier and Policy number art: -��ZS
No.:; 71 0
-�a/.�IfL__ Polity Z
trier. .l.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not becompletcd ifthe pmmil is for one hundred dollars DIM)
or less)
I certify that in the performance of the work for which this permit Is issued. I shall not
employ any person in any manner w as in become object to NC Worlous Compcvadon
Laws of California Dam
Applicant
NOTICE TO APPLICANT: If, after making this Ccnifcao of Exemption, you should
become subject in the Worker's Compensation provisions of do labor Code. you meat
forthwith comply with such provisions or this permit shall be deemed revoked.
onNLENDINGAGENCY
dou the is a constructionfor the pcdormance of
Iherbyich affirm Netdirtis•cd(Sec. nn7.
.)
' the work for which Nu permit ts issued (Sec.3(19], Co.Civ. C.7
Lender's Name-
landcr's Address
1 ecu fy Nen 1 lave mad this application and Mule that the above information is
COMCCL I agree to comply with all city and county OOIM CCS and rote laws relating w
Wilding construction, and hereby authorise represen ativrs of this City to Orion upon tic
above-mentioned property (or inspcceon purposes
w (We-) agree to save, indemnify and keep harmless the City of Cupertino Against
O liabilitiesjudgments. costs and C.N. which may in any way eecmc against said City
a in eovegmorgo of to granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON INT
Issued by: Date
SOURCE REGULATIONS.
°
Re -roofs
Type of Roof
Signature of ApplicantyConunmor I )Date-
aroHAZARDOUS MATERIALS DISCLOSURE
HAZARDOUS
Will the applicant or future wilding oeeupant Mom or handle huudous material
Is defined by the Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety
code. S—On 35333(.)]
Yes
All roofs shall be inspected prior to any roofing material being installed.
0
If a roof is installed without first obtaining an inspection, I agree to remove
Will urc applicant or future building occupant use equipment or devices which
mil haurdous air conumimmus to dcfincd by the Bay Ama Air Quality Management
all new materials for inspection.
Diwicn]
❑Yes u
Ih&Sidet Nona]Skimsmaterials nds Ne- Glifi,
( 1 /1 ��
Su.IuChe.duse if
ria Health&Safety CoM.Scetions23N13, 2S33J end 33334.1 undcrsland NMif upn fin
,25533nd!
/ r
�G�
Jars not currently have a mount, that in a my responsibility In notify tiro occupant f sere
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LLL
mquiremcnts nm IF It iMsaanccar.cek0caoC,Occap y
Signature ofApplic nt Date
S ��
All roof coverings to be Class "B" or better
Owner or molmn 9 Deo
CITY OF
CUPEkTiNO
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
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: a titer✓ LJ
Job Site Address:
Roofing Company Name:
A plicant s Signature: C J • Date:
ee
Greg tl
Building Official
Revised 1/30/03
Printed on Recycled Paper
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AD
CITY OF
CUPERTINO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
e>3 o S_�__�3
APN #
L� 6�
Date:
�� a3
BENERGY
Energy
BUILDING
Building Address
`M caw
Owner's Nam D
Phone #: 30 7 _,y/ 2 -
Contractor
Contractor:
Phone #:
License #:
BUILDING
so 9G -76 3
F'5 1/�4
Contact:
Phone #:
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)
Number of existing coverings
❑ Provide I.C.B.O. Report #
❑ To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and
Will Com 1 ith Cu ertino's Tear Off Policy:
Job Description: 0
Residential 39 a/a
Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of r iecct:^
Type o struction: Occupa cy group:
�_3
43 F0v
Qty. if
Applicable
Fee ID
Fee Description
Fee Group
1 BPERMFEE
l 2
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
7. 7