04030182CITY OF CUPERTINO -`
�' CO 1'TI2A TOR�t4b ATION,
- BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
04030182'
OWNER'S NAME:
PERMIT ISSUE DATE
ONE: -
SANITARY @AtOL NO.
ARCHITEC (ENGINEER:
-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
L '- ® -
1 hcroby a n. Nat 1 am licensed under provisions of Chapter 9 (commencing
who Smfi..7")ofDivision 3ofMeBoninand Profession Code, and my license is
inrmlfnroe infects
Lan cl S tae
REROOF
CONTRACTOR: M & S ROOFING Co. MAR 3 0 2004
D cOn'a°tor
ARCHITECTS DEC ON
I undCrsla d my plana sh.11 M Y9Cd a p tbli. meed,
BUIL. DING
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm Nm 1 em exempt from Ne Counselor's License Law for the
following meson. (Section 7031.5, Business and Professions Code: Any city or County
-
which mqulres a permit to eomwct almr, improve, demolish, nr repair any atmmum
prior to its issuance, also M4uims the applicant forsuch permit to rile a signed su dement
Umnad Law 9
Sq. Ft. Floor Area
Valu ati
that he is licensed pursuant to de provisions of the Contucur's (Chapter
(commencing with Section 7") of Division 3 of the Business and Professions Code) of
¢ 14 5 5 0
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant m a Civil penalty of
not mem Nan five hundred doll. (SSW).
01, as owner Orton property, or my employees with wages as theta sole Compensation,
31646047.00
Required Inspections
will do the work, and the svunum is nmimendedoroffered formic (Sec. 7044, Business
and Prefussiom Code: The Connector's m Lt.. Law denot apply m an owner of
q P
pmpeny w ho builds or im proves thescon. end who does s uch work himsel f or through his
own employees, provided that such improvements tae not intended oroRered tornado. If,
however, Ne building or impmvement is gold within can year of completion, Ne owner.
builder will have Ne burden of proving that he did not Wild Or improve for purpose of
sale.).
0 1, as owner of de property, am exclusively connecting with licensed commands m
convect the pmjen (Sec. 7044, Business and Profu irons Code:) The Conlracmr's W.
cams law does not apply m an owner of property who builds or improves Memel, and
who Connell for such projects with a contractors) licensed pursuant to the Convenor's
Litems Law,
0 I am exempt under Sec. . B & P C for this maven
Owner Dem
WORKER'S COMPENSATION DECLARATION
I hereby affimt under penalty of perjury one Of the following decimations:
1 have and will maintain a CeNOmm of Consent to aelf-iasum for WOrkner'sCompen-
ion, as Provided for by Section 37W of the labor Code. for the performance of the
rk for which this permit is issued.
1 have and will maintain Worker's CompensWon Imurance, ss required by Section
1037�'W
of Ne Labor Code, for me pertormance of Ne work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number are:
rtier. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Gluts medical need notlmcompleted lithe permit Is intone hundred dollars (SIM)
or less)
1 certify Net i the perfermuwe of the work for which this permit is issued, I shill not
employ any pCf ny mannerso ml eComC �bjeCtmtheWorkerfi Compensation
Laws of Calif i am
plteant
N Kr -Amt I,ANO
E APPLICANT. If, after making Certificate of Et mptio you should
th a subject to the Worker's Compensation provisions of the Labor Code, you must
formwith mor ply with such pmvisimt. to this permit shall bC dCemfd reMhCd.
CONSTRUCTION LENDING AGENCY
I hereby that mem is lending agency for tiro performance of
s ed (Sec 3
the work for which Nu permit ts issued (Sec 309'1. Civ, C.)
� which
Lender's Nsom
I
Lender's Address
1 certify that I have reed this applicmion and sate that the above information is
k
correct. I agree to comply with all city and county ordinances and sure laws relating to
Wilding construction, and hereby audon is representatives of this City to enter upon me
above-mendened property for Impection purposes.
City CupCmo
d keep harmless the of airlines,
(WC) Bgmm save. Indemnify NN
I Ilablllties.judgmm M. costs and expenses which may In any way seemC against mid City
I. comequcnce of the graining of Ibis permit.
' APPLICANT UNDERSTANDS AND WILL COIgLY WITH ALL NON -POINT
5 RCE REGULATION. C
�l a aC
Issued by:9 Date
Re -roofs
S mreOfApple�c mmelor vete
HAZARDOUS MATERIAL DISCLOSUR
Type of Roof
Will die applicant or future building occupant atom or handle hamrdous mamnal
as defined by the Cupenim Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(¢)?
❑ Yu �No
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 future building Occupant use equipment or devices which
mit hazardous it ccammi cats as defined by the Bay Area Air Quality Management
all new materials for Inspection.
District?
I4Nu
0Yes
\
I have mad the lmmrmms materials requirements under Chapter 6.95 of the Califon-
2550515533 anJ 2vul,yundersythewfinehuirthe
2Ila
met it ts me
no.
dins mol curtently hove a tenons. y re BiM1ility m notll'y the occupant of
does net
retim h must be et ssuanecof a Ccnifcam of Occupancy.
jgnaturje?'!q�f
is wh prior
Applicant Date
All roof coverings to be Class "B" or better
-,�
0 or authorized agent pare
Ic
'Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: -103R / PKIA e E 7-7- F,C A c e
PERMIT # 0�7 v
OWNER'S NAME: O q M
PHONE p� —
GENERAL CONTRACTOR; I
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following infnrmatinn-
Contractor Si ature
J/36-2/
D to
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
Septic Tank
Sheet Metal
Sheet Rock
Tile
Contractor Si ature
J/36-2/
D to
Community Development Department
Building Division
pt City of Cupertino
�ii111 10300 Torre Avenue
4 ' I pCCITY OF A Telephone: (408) 777-3228
V r C kT I l v 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: MoCAL 1` (�01-7
Job Site Address: /Q_U / TPZ4 E TT FGA//C C CC4N' �7�0
Roofing Company Name: t? 7
A plicant s Signature:
tGreg teel
Building Official
a G, 4r r Date:
44Y
Revised 1/30/03
Printed cn Recycled Paper
0
CITY OF CUPERTINOO3
OF REROOF 6 q
CUPERTINO PERMIT APPLICATION FORM
APN # ' /6 ,
� o ly—Date:
BUILDING
BENERGY
Building Address:103o2
FA,Ql7-
FZgce_ CL47 ;f7-7oV0
Seismic Fee Res
BUILDING
BSEISMICOM
Owner's Name: � !
't O EP L
C 0/17
Phone M.
1
BUILDING
M
BUSLIC
Contracnr:
�P one #: 3 ` qd
License #: Svuln
Contact:
Phone #:
Cupertino Business License #:
4&E -r
M 3 Z q
-0e
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
❑ Asphalt Shingles
61 Wood Shakes
❑ Wood Shakes
-❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings
�_
❑ Provide I.C.B.O. Report #
yd To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Ccupply With Cu ertino's Tear Off Policy: ❑
Job Descriptio gel-l0v f.
woD .f' ok
�� 0r Q� ,v � 71
7
�
Residential
Commercial ❑
Fire Zone: Yes ❑ No ®
Confirmed with Planning -Dept. if
there are any re t ctions: L!
Cost of Project:%y
Type of Const
c ion Occupancy g up:
fiv
Ile
Qty. if��
ADDliceble Fee m
Fee 17Psrrintinn
FPP r�Yll�ln
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
# g q q °3
I