04080205 CITY OF CUPERT[NO =Kx Sr" .x�rcYd. "os,kB�.a^b'A% '
BUILDING DIVISION PERMIT CONTIR`MTORANFORMA.TPIN
BUILDING ADDRESS: JEFF REY MILLER, GENERAL C NTRNG04080205
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY qftOL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
eZ t� Q Q
+rOp LICENSED CONTRACTOR'S DECLARATION Job Description
F I hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing
n� wlN Suction 70110)of Division 3 of the Business end Professions Co@,°ml my licence is
in full fora and cfrat
ceClm Daus.Cmm� ar REROOF /
p ARCHITECrS DECLARATION
I undemund my pians shall be used As public record,
it
i cod�n Licensed Professional
3 OWNER-BUILDER DECLARATION
Con cur
+� I hereby.(Sore that 1am.Bumps from Iho feemns CLASS:
S:A License Law for the
i o O following renen.permit
7031.5.construct.
Business ane w.dem m Cade:Any oily or county
$ whim regWrct•e.Also toFAILM the
sltec.W prow,demolish,ore pair my mmerure
prior M its licensed issuance,rsuant to t e the applicnt for ech permit m ice taloned atatemem
F=F < (that he commecalpuratunttoMeofDisioncofoe MeBusiness
LkennLaw
onsCodler9 Sq.Ft.Floor Area Valu tion
N thammenei=pidcc1ioar,and Us
but,frth alleged
meand Professions Code)or
$
that io b exempt Mtemlrom and ate bub it the MM exemp0=.Any violation of
Section than five
any Applicant(ora permit nbjecu the applicnt m a civil penalty of 3 2�31$b*kgr0 0 Occupancy Type
nm mom on fiw hundred eolWa(f300). -
❑I,u owns of the proputy,or my ,numaa mo wages t their ale704al B ration,
will do the work and th The Com le not Intended a Law
fondle(5=.to an Business
And Ro(aWobu Cade:The ver mactor,Luce en doh oot apps lf an owner of Required Inspections
Property who s,W or ed Matm oemoo.rte whorunt,ouch work himself edtluuugn but
ownaer,Me
that a=bImPmwmcthin am
taedor ledon.for colat..
however,the Wilding or improvement is els within ort yearw ampleeoa the ower-
W ilder will haw Mo WMn of proving Wt he did not build or improve for purpose of
talc.).
er of W property,am exclusively contracting with licensed contract.to
amirucI Me pmjat(Sec.70N.Business and Profession,Code:)The CoWacmh Li-
are Law data ral apps an an mama tiny who Wilds or improves Moron.and,
who cu fm such proJecu wi s,llice sedpuraem m has Con ora
Lice w.
❑
O iif
errept unser Se ,B&P mato
WORKEPS COMPENSATION DECLARATION
I hereby Malmo under pemlty,of perjury am of Us following dme Me
on
1 have Nfiate nM will maintain a Caof ran.., nlfl,. for Wmka'a Comport-
mile.,
amper
713711M
an,u provided for by Section 3700 of the LslmrClrde,for the perfunnana of the
rk for which this Permit is issued.
1 haw and will maintain Worker's Compemadan Imrmem.u required by Section
athe labor Code,far the performnce of the ooh far which this pemtt is issued.
Worker,Comperuation Wunna carrier and Policy number art:
rrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
(Misseetion dead et bccomple uliftne permh is form=hundred dollars(SIM)
or moa)
1 artify Mort in the perfamuna of Mc work for which this permit is issued,l shall not
employ any person in any mater an As an became subj=t to that,Workers'CompennMon
Uwe of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you Should
become subject b Mm Workers,Compensation provision or Mm Uba Code.you muss
OZ foMwith comply with such provisions or this permit Mall W licensed a eked.
Z OCONSTRUCTION LENDING AGENCY
I hereby olErm that Mort lex constmctinn lending agency for the performance of
a Me work fur which MIs Permit is issued(Sue.3097,Cih,C.)
4 Q Lendce,Name
=Z Lcater's Address
V 1 modify that I have mad this ppllcatian and Loam that Me show Information b
cenem.I agree in amply with all city and aunty ordinances And SUM laws MIWAI In
building commotion,and hereby authodm repremn aws or this cis In enter upon the
Lid Move-mentioned property for inspection purposes.
6. (We)acme m raw,indcmnify and keep hssmlu,Me City of Cupertino aeaimt
y II u.judgmenta.eotlsndea hich may In eywry acme gsinat cold City
C.>x ucncc aloe granting of thi L /
]CANT UNDE STANDS D COMPLY WITNALL L sued by: Date
E G 3
5.
Re-roofs
ignuum of AppliunV nuumr Dem
HAZARDOUS MATERIALS DISC-LD§URFTypeof Roof
Will the Applicant,or future Wilding occupant trore or haMm Z..material
ALL defied by the Cupertino Municipal Code.Chapter 9.13.and Me Hmlth rad Safety
We.Section 35s33(.)7
[-]Y. u All roofs shall be inspected prior to any roofing material being installed.
Will the applicantfumce building aaupam use equipmem m dcvlas which If a roof is installed without first obtaining an inspection,I agree to remove
hu
It henrenus air conum"
Di t enu As dcfined by the Bay Area Air Quality Management all ne materials for inspectio
ta Nu
hewmadoeht Naf out bmquimmenuunder Chapor6.95ofthe Califor- s,L
c o&Sdcty Codc,Sects 50,35533nd2553a.luocoaundM f build!
as of currently a m that l ' y San raibility m potiry upant a
rc r u is Rbe mm pod e f 0cte of ,/ nature of Appll nt e
wnormawhonv agent _ te All roof coverings to be Class "B"or better
Community Development
! '•J' 10300 Torre Avenue
1H ; Cupertino CA 95014
STelephone(408)777-3228
CITY OF Fax(408)777-3333
WUPERTINO
Building Department
J° Lt P F o x-0,5
OWNER'S N IA-)
H # —
GENERAL CONTRACTOR: a /
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
er or Signature a{e
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
UPE(�TINO 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 NajWe: ��I�D
Job Site Addre'39: D( ( /L
Roofing Company N0(: vtFFP-cf / / / I& L6ACJ
AP"
Signa
• Greg eel
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
00
REROOF ° `f " Z
CUPEkTINO PERMIT APPLICATION FORM
APN#,32 / /� UZ� j Dat (T _2 ,/C�io
Building Address 0-0
O /v V �/�6)C �_ jb& , Quo77,Tv
Owner's Name: / ` fit/ / / O[�J�� P/,�
ctt( :_/ R EoCn/CQ'�-����69 License 7J57J
Cont ct D Phone#: �� Cupertino Business License#:
7 � /CJ
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 Comply With Cu ertino's Tear Off Policy:
M76*
ob escriptio 1_ 0 it � '
Residential ❑ Commercial ❑ T
Fire Zone: Yes ❑ No ❑ Confirmed with Planning DWt. if
there are any restrictions: LJ
Cost of P o' c TyDe of Con truction: Occupancy group:
QtY
A I' 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