04060131 'I
;8U
TY OF CUPERTINO
BUILDING DIVISION PERMIT j_ bI) IIVFURMFI.00
LDINGADDRESS: FOUR SEASONS ROOFING PMMITNO04060131
195 POTTERS HATCH
ER'S NAME: PERMIT ISSUE DATE
DEANZA OAKS HOA 645 HORNING ST 06 15 2004
NE: SANITARY NO. CONTROL NO.
(408) 278-0330
ARCHITECfBNGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm Net I am licensed under provisions of Chapter 9(commencing :
with Section 7000)of Division 3 of the Business and pmfassiom Cm Ie,.nd my license is
n�2 In full force and effect. REROOF
License Cl a _L1.# � 77'x"
nip Date_7W usedAConturARCHITECTS DECLARATION
I understand my plans shell W used u public mcnrde
30 Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm Nat 1 em exempt from dm Contractors License Law for the
E00following moon.(Section 703 1,5,Business and Professions Code:Any city or county
x a t which roquims.permit to construct.alto,,improve,demolish.nr.,.it any nruclure 8000
Aa prions its issuance,Stan inquires the applicant for such permit to file a signed statement
g C that W is liccnseJ punuanl to the provisions of the Contractor's License Law(Chapter9 Sq.Ft.Floor Area Va tlOn
a zC$ (commencing with Secdon 70D0)ofDivision3of the Buslr.esond Professions Cade)or
3..
that he is exempt d.ralmm and the,basis fm de alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Subjects me applicant to a civil penalty of 4A&N-14VfAerU U OCCWy Type
not more man Eve hundred dollars(9510). ..
1,as owner of me property,or my employees wife wages AS their sole compensadon,
will do fee work and Me match.1,not in.nded oroRered fond,(Sm.7041.Business
and Professions Code:The Conmctor'S License Law docS not apply A an owner of Required Inspections
property who builds or improves maroon,and whodoessuchwork himselfor through his
own employees.provided rhatsuch improvements are not intended oroRered forsale.It..
however,the building or improvement is sold within am year of completion,the owner-
builder will have me burden of proving that he did not Wild or improve for purpose of
sale,).
❑1,AS owner of the property,am exclusively contracting with licensed contractors At
consumer the project(Sec.7044.Business end Profassimel Code:)The Contractor's U.
cense law does not apply.an owner of property who builde or improves daemon.and, ,
who convects for such projects with aeonmemKs)licensed pursuant to the Conurnmes
License Law.
❑1 am exempt under Sec. .B k P C for this meson
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of me fallowing deelvatiume
have and will maintain a CeNftcate of Consent to WINnsu.for Workers Compen-
sation,as provided for by Section 3700 of me Labor Code,for me performance of MA
Permitwork for which this Permit is iazued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the lobarCode,for the performance of the work for which this permit is issued. "
My Worker ns� o 7p na conic,and Polity number am: i
Cartier. , Policy FROM
'
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMPENSATION INSURANCE
(This section need nos W completed lithe permit isforana hundred dollars(SIM)
or les&)
1 certify that in the Performance of the work for which this permit I$issued,l shall not - --
employ any persen in my manner so as in Wromc subject to tW Workers'Compensation
Laws of California.Data
Applicant '
NOTICE TO APPLICANT:IL after making this Ccmr..ta of Exemption,you should
become subject in the Workers Com coram n previsions of the labor Code,you must ..
QZ forthwith comply wW
with such pr.. e.or this Permits hall W dccmcd invoked.
Z CONSTRUCTION LENDING AGENCY
'rt Ihereby affirm that marc it a construction lending agency for fee performance of
Ix dm work for which this permit is issued(Sec.301 Civ.C.)
l�Q Lender's Name
z Lender's Address
U Q 1 camily that 1 have read dais application and Bram fast me above informed..is
coma I agree in comply with all city and county mummies and sum laws mlating to
0O building construction,and hereby authofire mishaemalivcs of this city to enter upon Me
CA
move-mentioned progeny for impcctiun purposes.
LL (We)agree Io save,indemnify and keep harmless the City of Cupertino against
A liabilities,judgments,costs and expenses which may in any way Smote againslseid Ciry
U Z in consequence of the grand of this permiL
ati APPLICANT UNDER DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
OURC G L T
'o� Re-roofs
ignat of pile connector Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building Occupant or handle hazardous material
As defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
ode,Seetim 25532(0) All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑N.
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 hamodous air contaminants az defined by Me Bay Area Air Quality Management all new materials for inspection.
Emitter'
O Yea [3 No
Ihavc mrJ me havardn atcrialsrequirementsunderChapnti.95ofmcCalifon-
niaHaalthg,SafctyCadc,Sr a 25505,25533.nd25534.1undam.ddaetifthcWilding ��GY
docs not cummly hove n t,Nem it u my responsibility m notify dm.ccupmtt Df me
rcquimm which. sb At pd.,I.issuanea Of.Cardficate of Occupancy. Signal re of App(Cant Date
All roof coverings to be Class"B" or better
Owner aumofim cnl Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
" Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
16119Y OL16160 /
OWNER'S NAME: /a omG PHONE # d g Z7 -0>3d
GENERAL CONTRACT 4 FAX # eyv8 279-0 3
I am not using any subcontractors: &I'- 15'TJ y
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
Owner/ on actor ignature Date
Community Development Department
Building Division
I City of Cupertino
10300 Torre Avenue
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 " 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: Qt-ANt/) 'Mr--S _ F61*
Job Site Address: S FVAV5 A
Roofing Company Name: / rjEt}SOnrS Q
ri
A plica Signature: Date: 6' is_10/Greg teel
Building Official
Revised l/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF -D `�
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
3 �z 3s� os�-,� . 6-/s-may
Building Address:
DI95 �o�rs
Owner's Name: Phone#: g410 Vo 7 Z
Contractor: Phone#: �pg ,z2g-o g ya License#:
N5404 Zk, 972408
Contact: Phone#: Cupertino Business License#:
,Q/h7i S/Oig 27f�-o�i3o
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑. Built-Up roof
❑ Asphalt Shingles WKAsphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
✓Other(Specify) e&jWAAW ❑ Other(Specify)
N;7bDer of existing coverings / ❑ Provide I.C.B.O.Report#
B' To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 6r4w4
'Mow
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group: r
g �— ,ate s i=
Qty. if
Applicable 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
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