04080122 CITY OF CUPERTINO
r BUILDING DIVISION PERMIT ,C,ONTIUCTO XN UY,iMAT 'Olt!`
BUILDING ADDRESS: PERMIT NO.
SHELTON ROOFING 04080122
OWNER'S NAME: PERMIT LSEUEDAT6
12
SANITARY OL NO.
)NE:
ARCHI7EC NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� l�
900 LICENSED COMRACTOWSDECLARATION Job Des
w 1 hereby affoo that l em licensed under f�mvisions or Chapter 9(commencing
i with BeniprylNIFNALLU
0(X11 of Division3ofiheBusinau anADrOfcasiuwtode�end mylieenae is
p mull ander( t. ��//"" REROOF W/SHAKES
pYl`toZ, Licen CI cur# Alf 17 2004
n s- Dam Conueclor C m
ARC
CshHaDll M used tie puWrION
Led Professional s
BUILDING
WNER-BUILDER DECLARATION
1 herchy affirm that I am exempt from the Convector's License Law for the
0 o following reason.(Section 7031.3,Business and Pmfesnons Code:Any city Or county
K$(v which¢quires a Permit m cre,roo .aper improve,demolish,or repair any structure
i- roof 0 its issuance,also requires the applicantforauch permit to file a signed statement
ss< that W is licensed pursuant to the provisions of the Common's Liana Low(Chapter 9 Sq.Ft.Floor Area Valuatcn
Fto (commencing with Section 7")of Division 3 of the Business and Professions COO)of
that he is exempt Ocrafrom and the bouts for On alleged exemption.Any violation of �i�h'av,y
Section 7031.3 by airy applicant for a permit subjects the applicant 10 a civil penalty of 3 2WN W0ii 0 Occupancy Type
not mart than five hundred dollars($500).
❑L as Owner of the property,or my employees with wages as their sale compensation,
will do the work,and daeswcce,i,muinended moffened Rustic(Sec.7044,Business Required Inspections
and Professions Code:The ConvamorLiana Law LiLaw Class trot apply to e DS an owner of - Q p
prapeny w ho builds or im proves daemon,and who does such wart himsel f or through his
own employees,provides thmsuch improvements art not intended oroffered for gale.IL
however,the building or improvement is said within one year of completion,the owner,
builder will hese she burden of proving that he did not Wild or improve for purpose Of
ale.).
❑1.as owner of the prapeny,am exclusively contracting wide licensed convectors to
construct the projecl(Sec.7044,Business and Frofesuons Code:)The Com ader't Lt.
cense Law does not apply to an owner of property who Wilds or improves daemon.and
who contracts for such projects with acantuctoKs)licensed pursuant to the Convector'
License Law.
❑I am exempt under Sec. ,B k P C for Nes resson
Owner - Data
1MWORKER'S COMPENSATION DECLARATION
I hereby alarm under penalty of perjury one Of the following declarations:
I haw:and will maintain a Ceniftcate of Consent o self-insure for WorketaCompen-
anion,as provided for by Suedon 3700 of the Labor Code,far Ne performs..of the
work for which this permit is issued.
❑1 have and will maintain Wurkcri Compesnatian Wumnca,as acquired by Section
3700 of the Labor Code,far the,performance of the work for which this permit is issued.
y Worker's C�ompornime/n ln�sumnce artier end Policy number am:
.lf�{� FL4/)C� Pa11ryN.:/ W4 0/12063O
CERTIFICATE OF EXEMPT( OM WORKERS'
COMPENSATION INSURANCE
(Thisiumdon need not W completed If the permit Itforone hundred dollars(SIM)
Or lass.)
I mi ify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an as to became subject to the WorkersCompenution
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's ComPmmtion provisions of the Labor Code,you must
.J O foMwilh comply with such p rniisimu or this permit shall W deemed mvnked.
rCONSTRUCTION LENDING AGENCY
'r Ihereby affirm that dsc,is a construction lending agency far to performance of
Rai > dac work for which this permit u issued(Sec.31197,Civ,C.)
GQ Lender's Nanta
z Lander'Add.
()0 I certify Nat 1 have read this application and sum Out the above information is
(i. correct.lag=to comply with all city and county ordinances and sate laws relating to
O V building construction,and hereby aueartm reprtsemniva ofides city tocmerupnn the
W ahove-mentioned property for WPOCOm Wrpoaa
(Wc)agree to save,indemnify and kap harmless the City of Cupertino against
(z) ltabtlificajudgmemacostax do rues which may in any way we=against aid City
(„)z in consequence of the gmnun f Nis permit
APPLI RSTA S AND WILL COMPLY WITH ALL NON-P01 Issued by: Date
SOU ERea�
EG L f0 A / OGl
o / Re-roofs
Stppffi.of Applic COalracla Da
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or future building Occupant store orhandlc hs�ous material
as defined by the Cupertino Munidl el Cade,Chirac,9.11,and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 9Ao
Will the applicant or future building Occupant use equipment ar devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit h imodaus air Conm unanb as defined by the Bay Area Air Quality Management a mater OT inspectio
District?
❑Yes �Nu
Iheve mad daehvardnus aerialsmquimments underCheptcrfi95 of Nc Califon
nieH IN&Safely Code,Sectio 8505.25573 and 25534.1 undersand Nati(the WiiJing U
s not cu ndy haw a en Nat it u my responsibility to early the occupant of the
mqui me whichmuu etpriartoicatrutcofeC 'Rcamafoc anryG uC ignat re ofApplica Date
Owner
orsumorivsa ant Dam All roof coverings to be Class "B" or batt r
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De ent
JOB ADDREE$,7 l o/el-0 �j�cc r/�� D2. PERMfr#
a- e C) 17 , 0YO/7- Z
OWNER'S NAME: Pe,,,Ir /- /Greg e+7 ✓ PHO S/o �/0 25 3S
GENERAL CONTRACTOR: FAX #
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
Roofings
Septic Tank
Sheet Metal
Sheet Rock
Tile
g iG o
er/Contractor Signature D to
Community Development Department
Building Division
JCity of Cupertino
10300 Torre Avenue
OCITY OF Telephone: (408)777-3228
UPER,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.
m
Homeowner's Nae:J0/ �,
Job Site Address:
Roofing Company Nim ��2(� ov` ��vo�.n c� C o ,
A plicant's Signa 4 Date: iG p
T
Greg
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# , Date:
6 0
Building Addre
/Olyb
Owner's Nam Phone#:
A- <" 1� ra. �cr LJOk� - �7t0 '2S^�S
Contractor: Phone#: Licensey.
SHeI �c�h N JJ};n C'�. TrC Z�SD 9(0/-76g ;2_(O1O
Contact: I Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
X Wood Shakes ;�c 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:
Job Descr' don:
`3b.��c e C cso Ci-IQQ r� o�-�
Residentiaro Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dppt. if
there are any restrictio :
Cost of Project: Type of Construction: Occupancy group:
D 2r - rocs
Qty. if
ApplkwVe 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