03080155 CITY OF CUPERTINO fir" �^'
BUILDING DIVISION PERMIT CONTRACTORINPORMATION
BUILDING ADDRESS: COSMOS ROOFING PERMIT N003080155
NER'S NAME: 1901 OLD MIDDLEFIELD .WY PERMIT ISSUE DATE
NE: SANITARY 0. CONTR04 NO.
(415) 493-6373
ARCHITECT/ENGINEER: BLDG BUILDING PERMIT
MECH
io0 LICENSED CONTRACTOR'S DECLARATION
I1 hcmby efOrm Net 1 am lianacd under provisiona of Chapkr v kommcnaing Job Description
ii with Section]UID)nf Division Sof the Business entl Profcuinna Codc,end myliccnu is
in full force Aad of
>qz uanr , Lie.N REROOF FINAL.ED
h p Date O Contrukr
ARCHInC7S DECLARATION _
f l understand my plans ahAl1 W used a public records NOV 1 .7 2003
e C Licensed Professional
OWNER-BUILDER DECLARATION
I 1 naso affirm that I our exempt from the Contractors e:An,c Lew for the BUILDING 00 following uiresa Section ermitt ]fnt5,Business mrve.demolish,
Code:Any city OrcountypV ' 00
5$� which requires a permit m cnnslroc4 ester,improve,dcmnlieh,lir repair any sWctum
poor In its issuance,also requires the applicant for such permit to file a signed sukmetn
a< that he is licensed pursuant to the provisionsorobsCoctur'aLicenulaw(Cheper9 Sq. Ft. Floor Area Valuat on
ntn
Zl- u(commencing with Section Division).(the B usineand Professions Code)or
ERE
Net he Is e, ono them(,..and Ne basis for du dleged exemption.Any vvilmour of
Scetiop]03 1.5 by any applicant for a permit subjects the applicant to a civil Penalty or .AEN Number Occupancy Type _
not more than five hundred out)..(ML '" '"_ _ _
�1,u owner of the property,or my employee,with wages a their xolc eompenallmn,
will tlo Ne work.and NeaWcturt is not inkndcd orofferttl fanale(SecJDs4,Business 305 — FRAME
And Profession,Code:The Contractor's License es law donest apply to m owner of Required Inspections
property who build,or improves themon,and who docssuch work himselfor through his 307 - INSULATION
own employees,provided that such improvements arenolimendedoroffered(orate.If, 601 - ROOF TEAR OFF
however,the building or improvement is sold within one year of completion.Ne Owner.
builder will have our When of proving al he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
ale.). N603 ROOF BATTENS
❑L u owner of the property.,Business exclusively convecting wide:)TheeC aonVackn ro
come,ml Law oes norpply 10 in
ofprop Profesoomds or i The Contrsmors Li 604 - ROOF IN-PROGRESS
cease law dans not apply to an owner of property who build.or improve Nerton,and
who contacts for such projects with a contncmr(p licensed pursuant to the Contractor's
Lice Am law.
' lean exempt under See ,B&PCfor this moon
mar Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one or the following declaration:
I hew and will maintain a Ccnlfimle of Consent to sel6c.im,for Worker,Compere
,.tion,As provided for by Section 3700 of the LA WT Code,for the Performance of the
wo As for which this permit is issued. .
ave and will maintain Worker's Compensation Insurance,As myuiud by Section
00 of the labor Code.for the performance of the work for which this Permit is issued.
y Worker, i Iany�yp�pcae�con�iSrr and Policy her am:
Cartier: o Policy No X02 •/i
CERTIFICATE OF EXEMP ION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need not W completed irthe permit i,fm one hundred dollars(SIM)
lir las)
1 cenify that in the Performance of the work for which this Permit is tamed.I shell not
employ any return in any manner m As to become subject o the Workeri Compensation
Laws of California.Dam
AFAle nl
NOTICE TO APPLICANT:IL after making this Ccnifimm of Exemption,you should
become suhjecl to the Worker's Compensation provisions of the Labor end.,you most
= ,Z forthwith comply with Such provisions or Ni,POMIL Shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby Affirm that there is construction lending agency I'or the Performance of -
Y. the work for which this permit 11 issued(See.JP)],Civ,C.)
1 0 Lender's Name
z Lender'sAddress ,
:.l C) I minify dust 1 have read this application and side Net the above iafotmuiun i,
y f~ cancer.l ague to comply with all city and county ordinances and state laws relating to
�O Wilding convection,and hereby auNorbe erreunmim,of this city to coac"Nn the
above-
1 mentioned propcny for insfu npurPoua
(We)ague to save,indemnify and keep Windlass the City of Cupertino against
~fA liabilities,judgments,costs and expenses which may in any way seems against said City
J Z in conseyuencc of Ne ling u(Ihis slim'
APPLICANT UND Ahtq COMP ITHIALL N -POttfi' Issued by: Date
SOURCE RE (�/�'
Re-roofs
Signawrc of AppliwHAZARDO Dak
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the Cian ar(Muni buildMunicng ipal Code,
Chaptnava.and the
Health and
d
efined by the Cupen Municipal Coda CM1apen9.l3,entl Nc Health entl Safcsy
Simon.zssaz(a)+ All roofs shall be inspected prior to any roofing material being installed.
C]Y.. No
Will the applicant or future buildingmeuratd use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
haurdna air con inane a defined by the Bay Area Air Quality Management all new materials for inspection.
❑Ye,I have maJ Nehaardous makriels uyvimmcnu under Cherer6.95 o(Nc Califnno Sefm c,Secdans 255.5 llmd25534.1nolily W, Wfi lmdn'"Ibid if thc ldingmol canto w lie yrespo litym lily the scup tnf c
alp r of lo ,Signature ofApplicant Date
'
Owner ser awhori'rcd agent Date All roof coverings to be Class "B"or better
- � '
Community Development Department
Building Division
r City of Cupertino
10300 Torre Avenue
CITY OF
Telephone: (408) 777-3228
4UPEkTINO 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 polion re-roofing.
Homeowner's Name: 004. ✓LF.1 -
Job Site Address: la 2 D
CIOZ-
Roofing Company Name: a
A plicant's Signature: 6 0
Date: 3
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO 1-
REROOF o3
CUPERTINO PERMIT APPLICATION FORM
APN# Date: ` 0�
Building Address:`,Z d
Owner's Na�me� Phone#: 6 7 11J6
Contra�oo�p Ph #: License#:
(�,yn•,,,,� ��S 9 69-76 0 ��S�C41/
Contact: Phone#: Cupertino B1 sipes 'cense#:
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#
}k To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 771—C., • U- k . a_aV (/-
Residential ❑ Commercial ❑
Fire Zone: Yes '❑ No ❑ Confirmed with PI mg De t. if
there are any re ictions:,
Cost of Project: Type of Co c io Occupancy gr up
&75 • 0-0
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
1 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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20 2 z� o
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