03050007 CITY OF CUPERTINO "/� �,'�
BUILDING DIVISION PERMIT 4COI�RACTOR I—NFORMATIOn a
BUILDING ADDRESS: PERMIT NO
ECKSTROM ROOFING CO 03050007
1" A
)WNER'S NAME: 363 HARRISON AVE "'Nn
ERMIT L4Nn2/2003
SERNIG DONALD
NE: (408) 370-1628 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMnNNFO
BLDGELECT PLUMB MECH
0 E 0
Zp LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am licensed under provisions or Chapter 9(commencing �r a N LL pl
with Scmiw10)of 70( Division 3.1'the Business srW lhofens I. r ssmCode,and my ties.
'? ED
in full torn and artq ' REROOF
5 Lictc t 3 Lk.N TI�
a:� Dau Cantrwm MAY 1 9 2003
Y
ARCHITECTSDECLARATION 1 1
Y 1 untlenunJ my plana shell M uwJ u public records
iG
Licensed Professional BUILDING
I III DING
y
OWNER-BUILDERexemptDE DECLARATION �J L 1�Vw.N
�C a 0 I nanny.affirmsee Nal 1 1. exempt from the Cortins Co License taw for the
C p o whichfollowing e reason.(Section 8171.3,Businessr. and improve.
de Professions Code:Any city or county
$ which nyuirw•permit re cores the ever,improve,deermitt or repair ed structure
y primmits cense pursuant to tO dee vision orcant forMe sucContractors
LiMmso Bic a Law statement
�Y�Y< that hmencienua pursuant to the,of Division 3 theeBuwmriand Proison(Cnapter9 Sq.Ft.Floor Area $ �7®tlOn
y'O und'he is
SceHan 70110)ofiaiiion]orlMeged exemton,Any
Code)or
$ Nat M1e 4 exempt thucfrom and the hula for the alleged excmpllon.Any vloladon of
Swdon 701.5 by any applicant for a Permit subjects the applicant to a civil penally of 3 MaI]I L"erO 0 Occupancy Type
not mom than five hundred dollars(550).
❑ the
wrofIM prosody,re 1, aimencO withwagee r sia(vele compewness
and dothcwons end the he Com isunesLnded orawdoeffered oras apply 71 an Owner of — ]� �ryd Inspections
and property
soh ons Code:The Conmeton, ndwho law dens not apply lf an owner of 307 - I NSUthefl p
propertywho s.proeremprowa thereon,endwho son mni vendhimselfer through his
hOwn owemployrsa,proWded vel suchimprovements
sold nuwnot naso c mplecmA fm owner, 6O1 — ROOF TEAR OFF
h deer the building orImprovementisrowa didnotleyeti of completion,Ne owe of
builder will Nva the Wrden of proving that he tlitl not build or Improve for purpose of 602 - ROOF PLYWOOD NAIL
iA.). 603 - ROOF BATTENS
❑I.as owner of the property,am exclusively contracting with licensed mnttmoms to
construct the pmjeu(See.7044.Business and Professions code:)The Cmm acmla u- 604 - ROOF IN-PROGRESS
tetra Law docs not apply to an owner of property who Wilds or improves thereon,and
who convects for such projects with a contrwmr(s)Imesed pursuant to the Comuse mes ,
License law.
0 l am exempt under See .Bk P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affsrm under penalty of perjury oro of the rallowing declarations:
I have and will maintain a Certificate of Consent to selydnsum ran Worke'.Compcn-
uatum,as provided for by Section 770 of the labor Code,for tiro per5wor am a of ted
woh permit
for which this is issued.
C3I hove and will maintain Worixes Compaofion Insurance,as required by Seedon
370 of the labor Code.for Ne performance of Ne work for which this permit Is issued.
My WorkeYs Compassed"Insunna Orris,and Policy number art:
artier. Polity
TTTEReIF' N
CATE
OF EX EM FROM WORKERS'
COMPENSATION INSURANCE
(This section wed nutlwcmnpicted if the Permit is rwene hundred dollars(510)
nr Ws)
1 certify Net in Ne perfornmem of Ne work for which this permit is issued.I shall not
employ any person in any manner an As to become subject to dee Workers'Compewtlon
Lewd of Calilmoin.Dau
Applicant
NOTICE TO APPLICANT:If,after making this CeniBca a of Exemption.you should
become subject to the Worker's Compensation previsions of the labor Code,you must
,J Z foMwitn comply with such provisions or ds Permit shall be deemed rooked. .
'Z O CONSTRUCTION LENDING AGENCY
[r I bemby afRtmthel time is a consto don wading agency for the Performance of
6i > the.,it for which this permit is iuucd(San.3W7,Civ.C.)
CA Lender's Name
z Iandefs Adtlras
U0 1 certify that 1 have rand this application and sus that the show information is
cormeL 1 allow to comply wits All city and county ordinances and saw laws misting u
0 building convection,and hereby authorise wPreunmim of this city to enter upon the
W above-mentioned properly rot inspection purposes.
(We)agree in ore,indicatory and keep ha^nleo the City of Cupmino against
ccn Ilabllitics.judgmens.costs and expenses which may in anyway accrue,qunstuid City
()z in APPLICANT eof Me UN ERSfAND thisof permit.
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE E1
Re-roofs
Signature of ApplicanVConuaclor Card
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building o xt store or handle havardous material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Cent.Seceon3s533fa7 All roofs shall be inspected prior to any roofing material being installed.
❑Yca FANO
Will the applicant or future building occnp=nt nee equipment at Jcvicea roman If a roof is installed without first obtaining an inspection,I agree to remove
mit hanomus air cormon, n u defined by the Bay Awa Air Quality Management all new materials for inspection.
District?
❑Yes No
Ih A, readthehmudoms 25505lsrcqui And
2553nderChopur695af he Cilifor
nix HaWhrntly howc,Sections25505,25533
my responsibility
undesssede Occup Wilding
sans not currently hew a tenan4 Nu it s my rcsponsihilhy m notify the wcupw of the
m�ym^mmcn�whichmustWp�armiasaawenraccrurwamoraapancy, Signature of Applicant Date
owner .g .m- All roof coverings to be Class"B"or better
onmhcrimdagem
Community Development Department
I Building Division
City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
T,]N Fax: (408)777-3333
C U P S
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: b6lti&p TTt--SE�/U I6
Job Site Address: 76'`11 PtA-- L ,BL,OZ OM OR
Roofing Company Name: Tb Al 90,9 F/I✓6 Cd
a 1� Date:
3
eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
yof REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: n
Owner's Name:' pt/ / /I hone#:
Contractor: ' 1 / Phone#: License #:
c><cS)ko>Vl AdoF/IvG CQ oS 37e --16a_8
Contact: Phone#: Cupertino Business License #:
c M 3 �o— !6','z
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof.
%I Asphalt Shingles U 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.
iI Have Read, Understand and Will CornVIV With Cu ertino's Tear Off Policy: ❑
Job Description:_ U r
Residential Co ercial E]Fire Zone: Yes LJNo ❑ Confirmed with Planning01f.
there are any restri ' ns:
Cost of ec 02� Type of Constructio r Occupancy gro
Qty. .
A 1' a e Fee ID Fee Description Fee Group
VB
PERMFEE BldgPermit Fees BUILDING
ENERGY Ener BUILDING
SEISMICRE Seismic Fee Res BUILDING
SEISMICOM Seismic Commercial BUILDING
PLANCHK Plan Check Fee BUILDING
USLIC Business License BUILDING