04060177 CITY OF CUPERTINO 1711
BUILDING DIVISION PERMIT GAN`'•T1CUR'TNI''QI.tM'A.TIOl ,:.
a ,i.
BUILDING ADDRESS: FOUR SEASONS ROOFING PERMIT Nc04060177
10144 POTTERS HATCH
OWNER'S NAME: PERMIT ISSUE DATE
lab DE ANZA OAKS HOA 645 HORNING ST 0CS/21 /2004
ONE: SANITARY NO, CONTROL NO.
(408) 278-0330
ARCHITECITENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u O o LICENSED CONTRACTOR'S DECLARATION
UW 1 homily affirm that I an licensed under provisions or Chapter 9(commencing Job Description
with Section 7001)of Division 3 of the Business and Pmfesalons Codc,and my license is
5 _ m, lI m amh°c `' �D u (J'7216
� REROOF W/COMP. SHINGLES
n FQQ 999 Dam Tr - AhCNITECI-S
DECLARATION
I understand my plans shall W used as public records
D�
G In Licensed Professional
OWNER-BUILDER mDECLARATION
0 1 motor.
.Elan on I am exempt from W.Contractor's :Any c Law for the
O following reason.(Section]coir t,that, and Proimprove.
Moore Cade:Any city or county
lyeiLL WM=h I%issu apermit Illeonas Mepplic ImpmM,h Permit
or repair anytWment 8000
�1 priori itscense pursee. nt to the
Novisio sootheant for wchpermit mfiensele a signedstatement
asthatbeencingwitpursuant70th)provisionsofthe eBusiness
uuessandcnxlaw(C Code)or
Sq.F[.Floor Area Valuation
z�$ that
ii(commencing Section 7000)M basis for
oftheeged essmptona.Any
Crete)or
gut he a exempt ihem(rom end Ne breis far Ne alleged emmptlon.Any violation of
Section 7031.5 by arty applicant for a permit subjects Ne applicant in a civil penalty of @ Occupancy Type
not more Nen five hundred dollars($500).
Q I,as owner aide property,or my employes with wages as Weir sale compensation,
will do the work and Weamicum anminanded oronered partial.(Sec.70m.Business
and Professmm Code:The Contmcmes Lienee Law data net apply m an owner of - - Required Inspections
progeny w ho bui Ida or im proves dtereon,end who does such work himsel f or W rough his
own employees,provided Williams Improvements enc nmintended oro@red for We.If,
however,We building or improvement is said within one year of campledon,the owner.
builder will have We burden of proving that W did not Wild or improve for purpose of
sale.).
❑1,as ower of the property,,R exclusively contracting with Code:)
conRxtars m Q
carseat We project(Sec.]Dad,owner
of and Professions Code:)The ves Woman.Li- 7
eche law docs not ro an owner of property who sed or improves thereon.an, -
Lima.La mfar¢nth projects with aCDntrxmr(a)Ikeved pursuant to the CDngxlofa
License Lew.
❑tare exempt under Sec. ,B$PCfor Wis rcazan D�
Owner Dale
WORKER'S COMPENSATION DECLARATION
41 1 hereby afErre under penalty of perjury one of the following declarations:
❑I hese and will maintain a Cendmate or Consent W self-InsureforWarlixesCompcn-
satlon,m provided for by Section 37110 of We Labor Code,for We Performance of the
work for which this permit is issued. j
❑I have and will maintain Worker's Compensation Insurance,az required by section
3700 of the Labor Code,for the performance of the work for which this permit is issued. -
My Workers Cnm emadsonn insurance tamer and Policy number am:
Cartier: 15 t� 1 ] Policy No.: 2Z r
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not W completed if the permit literate hundreddollars($I00)
or les)
I certify that in We performance of the work for which this permit is imbed,I shall net
employ any Person in any manner an u to become subject to the Worknof Compensation
Laws of Califomia.Dau
Applironl
NOTICE TO APPLICANT:IL after making this Cori of Exemption,you should
become subject in the Worker's Compensation provisions or We labor Codc,you must
OfoMwith comply with such provisions or this permit shall W demcJ raveled, l
ZCONSTRUCTION LENDING AGENCY
y
(—� I hereby aprons that Were is a construction lending agency for We performance of
a 7 We work for which this permit is issued(Sec.3097,Civ,C.)
QLender's Name
Z Lender's Address
V 0 1 certify that 1 have mad this application and state that We above information is
IZ,H cora,I agree in comply with all city and county ordinances and state laws relating to
OU building construction,and hereby authorim representatives or this city to enter upon We
4kl above-mentioned property for inspection purposes.
Da (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and talismans which may in any way accrue against mid City
V 7 in consequence of the granting of this permit.
r^• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Da[
SOURCE REGULATIONS.
Re-roofs /7
Si,.,..of ApplicmDete
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will Weapplicant or future building occupant Charter 9,12,
handle Health ad
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Sefcty
Adlicoda.section 25532(a)? ao All roofs shall be inspected prior to any roofing material being installed.
❑YCs
Will the applicant or fuum building occupant use equipment or devices which If a rOO*talled-without first obtaining an inspection,I agree to rem ve
emit hazardous air conmminants as defined by the Bay Arca Air Quality Management all new aterials for inspection.
District?
❑Yes
I have read the hazallous materials requirements under Chapter 6.95 of the Calt o-
na Hcalth&Safety Code,Smucm 25505,25533 and 25534.1 understand ths,Bum Wilding / mss
docs not"mee
tly ha sant Nat it is my msponsihility w minty We acupant arp We _ !/
ncgtl pdoruissuancDf3CCNticateOfOccuP cy, SignatureofApplicant Djife
Owner or amt oared agent Dote All roof coverings to be Class nBn or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
4c�L, 6 c�o ( -?
OWNER'S AME: PHONE #
GENERAL CONTRACTOR: C—Ya�,� FAX #
I am not using any subcontractors: 2 z G
Signature Date
Please check applicable subcontractors and.complete the following information:
60 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
C
ontractor Signature Date
f
Community Development Department
Building Division
City of Cupertino
ml 1�17 10300 Torre Avenue
01 Telephone: (408) 777-3228
CITY OF Fax: (408) 777-3333
UPEkTINO
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: SDos—A S `jprr; **-7
Job Site Address: /Uy '01,25 e5K�
Roofing Company Name: OHv
A plicant'ss�Siignature: ate: � 2L/0
\A/�S1.hSD�X)
• Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF 0 °
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Na e.
Contractor: Phone#: Lice se#:/�Z/d
� S — 7
Contact: Phone#: Cupertino Business License#:
�L� • ` —� 5�1� -8/y Z Z
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ti'?, Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles /] ❑ Wood Shingles
>c 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 Description:
FZ�or� S
Residential OKI Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plannin Dept:if.,
there are anrestricti s: LJ
Cost of Project:oType of Co c 'on: Occupancy group:
(ryG
D G
Qty—,if
ArAlic4le Fee ID Fee Description Fee Group
BPERMFEE Bld Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING