04010093 CITY OF CUPERTINO ' '% G^•'' ""�"�'�§" `" ''
BUILDING Dlvlslory PERMIT xCONUXOT„OR=I FORMATION g
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BUILDINGADDRFSS: SHELTON ROOFING PERMIT NO 04010093
�10 RAINBOW QT
OWNER'S NAME: PERMULSSUEDATE
E �
SANITARY AOL NO.
ARCC
HITECTI NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o o LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am limned under previsions of Chapter 9(commencing Job DesCt�■A��®
with Scnion 70110)or Divixion 3 of the Bwonevand Pjofcssiom Co and my icenm is �„�YYM
^ y in full fome a c[Vmm Z.(0 d
3~Vizq 10 area L REROOF FEB 2 4 2004
3 Date . ARCMt
< I understand my plans shall W used m public am ds 1, , n
;0 Licensed Professional BUILDING
OWNER-BUILDER DECLARATION
i<2 I herchy affirm that I on exempt from that Conuaam's License Law(or the
ZOO following reason.(Section 7031.5,Business and Rofcmiuns Code:Any city or county
$ which mquims a permit to construct,alter.improve,demolish,to repair any swctum
_Za
poor o its issuance,also requires the applicant for such permit to Nc a signed statement Qocn
Fthat he I,fieconed pursue.,1.the owin!....I the Cimimcun't License Law(Charter 9 Sq.Ft. Floor Area Valu tion
gyp$ (commencing with Section 7BOD)of Division 3 of the Business and Professions Cale)or
3 that he is esempt Nemfmm and the basis for the alleged exemption.Any violation of ,A,py���7�.� y�
Section 7031.5 by any applicant for a permit subjects the applicant a civil Penalty of 3t5ti aSO V'�YerOO Occupancy Type
not more than fin hundred dollen(5500).
❑I,a owner of the property,or my employem with wages as their sole compensation,
will do the work and the snet..is not intended or offered for sale(Scc.70,14,Business
and POO(eadmiS Code:The Centneloes Liam,law does and apply to an owner of Required Inspections
pmpeny who builds or improve thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended oroffered for sal..If.
however,Ne building or improvement Is sold within one year of eompletian,the owner-
builder will have the burden of proving that he did not build or improve(or purpo¢of
axle.).
❑1,as owner of the property.am exclusively contracting with licensed combination to
construct the project(Sec.7044.Business and professions Code:)no Contractor's Li.
cense law does not apply to an owner of property who builds or improv themon,and
who contracts for such project with a emuamnr(s)licensed pursuant on the Contsactoh
License law.
❑1 am esempt under See. B&P C for Nis..on
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affum under pcndty of perjury ore of Ne following declarniam:
have and will maintain a Ccnificam of Consent to xel0imute for Worker's Compere
on,as provided for by Section 37W of the labor Code,for Ne parformane of the
work for which to,permit is issued.
have and will maintain Wmkeri Compensation Insurance,a required by Section
37M of the Labor Cale,for the performance of the work for which this permit is issued.
My Workets Campensai on lnaunnea eamier and Policy number art�:t CC''
Carrier, 5 �� Polity Norf�t'�J`10SK
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu minim need not he completed if the permit is for one hundred dollars uIU()
or mm.)
I amity mat in the beriumnarm of the work for which this permit is issued,1 shall not
employ any person in any manner so an to become subject to the Wormis'Compensation . .
Laws of California.Date
Applicant _
NOTICE TO APPLICANT:If,after making the Certificate of Exemption,you should
become subject m the W9rkR a Compeumim provisions of the labor Code.you mum
.J O forthwith comply with such provisions or this form it shall be deemed revoker.
'Z CONSTRUCTION LENDING AGENCY
[—r 7 y. I hereby affirm that there is a construction lending agency for the performance of
Ci 7 the wish for which Nis permit is issued(Sec.3091,Civ.C.)
W� Q Lender's Name
z Lcnder's Addmm _
U C) 1 certify Nu I haw read this application and sum Nn dui show information is
F COMM.1 agrm to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby amhorim reprcaentatiws of this city to enter upon the
purpo
;l.
4 ahovmms.judg d propertycosts
for inspection which ma
(We)agree to taut,indemnify and keep bumless the City of Cupertino against
F+0 liabilities.judgmenB.cosu and expenses which may in any way¢true against mid City
UZ to consequence of the granting of tItrmit.
f-t APPLICAN NDERST D WILL MPL`J WITH Aff{{..NON/POaItNT Issued by: D e
SOURCE UL I�N f /�T•
f- Re-roofs
Signature of ApplicantlConuacmr i Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hrmrdous material
as dinned by the Cupenino Municipal Code.Chapter 9.12,and the ficalth rad Safety
cafe.Sce0e,zss3ze.r. All roofs shall be inspected prior to an roofing material bei.
pYea — p p y g g installed.
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
haiardous air contaminants as defined by the Bay Area Air Quality Managemenl all new materials for inspection.
rico
❑Yes _ ,� (%IC
1 have mad the hanNnusmeteriels requirements under Chapter 6.93 of the Califoo- as I I 1
nia Health&SaftyCodc,Sadom25305.25533ud255N.1undcnlndthatifth building
Jens not current) aw a teens the it' my responsthility m nnul'y tic occupnt of ft 1
notion cnu m the y' ll�ssumccay'CcniE�amofOcev/ne
� Signature of Applicant Date
Owner or authorind agent Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
6 �0� 00 �
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# (0 ` Oa Date: /
Building Address: 7 /J �G� / ` e C L)
t%rvTi•frW /-
Owner's Na e: Phone#:
Contrac Phone#: License#:
G5� 96/-76 s 9 2- (,Io y/
Contact: J Phone#: 5 Cupertino Business License#:
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) T. P. 1K Other(Specify) U•S.'fc 4
Number of existing coverings ❑ Provide I.C.B.O.Report# 352-0
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
b Description: _ 7•ts") 7ytr»t,/rt6w t 1
I-its aw / 'r awaz ,2t
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning-Dt. if
-"'— there are any res itions: LJ
Cost of Project: Type of Cons tion/ Occupancy gro p:
A8 8S3 . uu
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
z �z;f
Jr z� XO
1 r
n Community Development Department
y Building Division
City of Cupertino
F1SSS��� 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
U P E IST I NO
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: y�CPiu e� ldz,�La..
Job Site Address: v�—/ 7/ U� pZM4, iCnrW C,�
Roofing Company Name: X`fC t -sem, / 5— /
A plicanYs Signature: Date: 7l� G A
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper