04100140 CITY OF CUPERTINO "'"`'"�'_
BulLornc QrvlsloN PERMIT CONTRAC`TORJNFORMATION:-.�
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BUILDING ADDRESS: COSMOS ROOFING PERMIT N04100140
8931 PENDERGAST AVE
OWNER'S NAME: PERMIT L55UE DATE
ELAINE KAWASAKI 1901 OLD MIDDLEF 10/20/2004
IONS: SANITARY NO, CONTROL NO.
(415) 493-6373
ARCHITEC1ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
=oo LICENSED CONTRACTOR'S DECLARATION
I herchy affirm Thu I am licerved under provisions or Chapter 9(commencing Job Description
with Section 7000)(if Division J of the B usineae and Professions Code.andmy license is
in farec It
and off 9 e,�e(� REROOF W1 TAR & GRAVEL
j n z Liccnsc Clys Lic.X y9 -
n F Dam ` OConi or
g ARCHITE
1 undcrsmnd my plans shall 1wu ea puhlie records
)�U
LLo Licensed Pmfcssional
OWNER-BUILDER DECLARATION
f 1 hereby affirm that I am exempt fount the Commeauf's License Law for the
02 fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improve,dcmnlmla,or repair any structure $5650
prior m its issuance,also requires the applicant for such permit m tilt oxigned,oncon1
that he is licensed pursuant m the provisions of the Contractor's license Law(Chapter 9 Sq.Ft,Floor Area Valuation
��$ (commencing with Section 7000)of Division J of the Business and Proassinns C<x1c)ur .
.- Net he is exempt therefrom and the boo for the alleged exemption.Any violation of
Section 7031.5 by any applicant for permit subjects the applicant to a civil penalty of Occupancy Type
not more than five hundred dollars($500). P Y YP
0 1,u owner of the property,or my employees with wages u their sole compensation.
will do the work,and the structure is not intended or anerctl for sale(See.]044,Business
and Pmfcssom.Code:The
Contractor's License Law does not apply to an owner of Required Inspections
rimpenywho builds.improve.thereon,and whode s such work himselfor through his NOV2004
Own employees,provided that such improvemenu are not intended oronered forsale.If. V
however,the building or improvement is said within one year of completion,Ne owner.
builder will have the burden of proving Nat he did not Wild or improve for purpose of
Coln.). BUILDING
I,as owner of the property,am exclusively contracting with licensed convectors Io
construct the project apply
to an Business and Professions Cade:)The vet thereon, nd
Cousin law contracts
f nmchp r e ts owner of property who ad p or improves Contra,and
whoonse Lacu for such projects with a comnctor(s)licensed pursuant to the Contractor's
License Law.
❑1 am eaempl under Sec. .B&P C far this rcuon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aRum under penalty of perjury one of the following declarations:
71 1 have and will maintain a Certificate,of Conserv to self-insure for Worke(sCumpen-
sedan,u provided for by Section 37M of the labor Code,for the performance of Ne
wyor�k for which this permit is issued.
1ry,1 have and will maintain Worker's Compensation Insurance,m required by Section
?00 of tine labor Code,for Ibc performance of the work for which this permit is issued.
My Worker's Cq`mpemasinn Zoe Is.or end Policy number am:
Cartier: �+' / r"`�1.� Policys.57 I _0 Y--/1-'"5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is for one hundred dollars($Iib)
it,less.)
I certify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any member an,as to became subject to the Workcri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Workers Compensation provisions of the Lobar Code,you must
,JO forthwith comply with such provisions or this perm it shall be deemed cavalier.
z' CONSTRUCTION LENDING AGENCY
f" IWreby affirm Nat Nese is a Convection lending agency for the performance of
F4 7Ne walk fur which this porous is issued(Sec.X197,Civ.C.)
l0 Q Lender's Name /
Z) z Lender's Add..
V Q 1 certify o C 1 have reed this application and duan that the shove information raisiing is
0 U correct.l agar to comply with all airy and county ntaivs Of and icy t laws relating ae
QU building g consuuction,and hereby auhops representatives Of INS City to cmcrupnn be
?' C shove.(we)agree
eepropertyran ser inspection aacep ha
(we)agree m cove,indemnify and tech harmless the City accrue
Cupertino id City y-v
H N inconeseq enceo the cost and extensor which may in anyway accrue against said City I
OZ incnnsequenee of the granting of this omit.
APPLICAN NDERST DS WILL MPLY WITH ALL N N-POINT Issued by: Dale
SOURCE ULAT
/O
�d a,L Re-roofs
Signature of Applicanueontracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future Wilding occupant store or handle hamoluus material
as defined by Ne Cupenino Municipal Code,Chapter 9.13,and the Health and Safety
CMc,Section
35533(x)?
❑Yess LNC_ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hv3mnux air Contaminant by the Bay Arca Air Quality Management all new materials for inspection.
Disuic0
❑Yes
1 hove read the haseadous materials requirement under Chapter 6.95 of the Califon /O
is HcalthA Ssfcty Sccuuns 85!15, Jt and 85J4.Iundcramnd mmifthc building ZG
Jars nm curtem ve s tonon m' y rcsponi icy m roily the,rreupont of the
so
u s Ip rt aan'ea eNnaa oracn�agey' Signature ofAppli ant Date
7— /L/°$ All roof coverings to be Class "B" or better
Owner ur awhorimJ ogcm Das
10x19/2004 L3:58 " "707-528-7663 PERMIT SERVICES PAGE 03/03
Oct 1.9 04 08: 528 - cosmos Roofing (6501969-9905 p.3
0 6 13/RC04 Ub:34 [RR 400 '111 3833 CITU' CUPERTINO toot/cot
C=mtmicy D"a mmt
10300 Tone Avmue
• thow(4 8)7 93014
' TolcpMan(408)777.3228
Pu(408)777.3339
CUPEI71mo
Bull din De artment
JOB ADDRESS, FEB.&=0
19 cl;5 1. PC—,V b oc-R,4,",r A-VOl{'/00/ q�6
OWNER'SNAME: jiHON10 L 8� '1
GF. EM CONTRACTOR: FAX li
I am not using ony subcontractors:
Sigrtattua Date
Please[heck applacaMe subconmectom and complete the following infornwtion:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets&Millwork
Cement FinishingM '
Electrical
Excavation
F4mct:t
b7oorhtg:
Linoleum/Wood
___.. Glass/ Glazing
• Heating
Invtilation
Landscaping
[.athing
Masonry
Omna wntal Sheet Metal
Painting/Wallpaper
Paving
Plaatering
Pl
RoeFing
Septic Tank
Sheet MOW
Sheet Rock
rue
�UWT rr/CC;T&actor5iguatum Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
WUP' EkTINO
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 manufactiuers 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: C�t.�rc cJ
Job Site Address: 6f g 3
Roofing Company Name:
A plican''s Signature: i Date:
CiVaSWDCXI
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper .
a'QCITY OF CUPERTINO o
REROOF
E
RT
OF
bCUPINO PERMIT APPLICATION FORM
APN# 37SDate:
Building Address:lml
Owner's NC � � Phone#:2–S 5 _
Contractor: Phone#: License#:
Gso 964-7G63 -2 gs iii
Contact: Phone#: Cupertino Business License#:
650 Foo- a yr 4
Type of Roof Covering:
Existing: Proposed:
Built-Up Roof A Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes _ ❑ Wood Shakes
ElWood 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 Policy:
_., Jobb es Ttion:�— . ..- -- -- __.._.-...
Residential Commercial
Fire Zone: .Yes ❑ No ❑ Confirme h Planning Det. if
there ar r, ctions: LJJ
Cost of Project: Type of Cons. Occup cy f
"5-650 . ov
ty:if
,Kpplicible 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
•