05060117 ` CITY OF CUPERTINO
BUILDING DIVISION PERMIT , CONTRAGTORTNF IiMA"Ct0)� zF
BUILDING ADDRESS: PERMIT NCb 5060117
11250 REDONDO CT
OWNER'S NAME: PERMIT ISSUE DATE
PAUL JENSEN 5
ONE: SANITARY NO. CONTROL NO.
ARCHIEC(ENGINEER: BUILDING PERMIT INFO
BLDG O PLUM MECH O
o p LICENSED CONTRACTOR'S DECLARATION
Ii I bemby afn.than 1 an licensed under provisions of Chapter 9(mmmmmi., Job Description
with 9Cedon TOW)of Division 3 of the Business,and Pnefu a e Code,and my license is
info]]form and eRxl�3 ct �,o p� V REROOF TO COMP.
lanes Linens Clan — l_. �J.L
n Da comncmt CONTRACTOR: JEFF BRIDGEMAN ROOFING
ARCHITECTS DECLARA I
g`u undnendmypheaahallbe daspublk SUBCON. : U-SAVE REMOVAL (!$26044)
G Licensed Professional
nor OW NE n exempt
m the Con cro
Q I ON
I hereby affirm thin 11. exempt from the Canine Co License taw for the
OO followingmoon.Permit
71131.3,Bualm. and tie,de ons Cade:Any rm or county
$f<i which rtq.ms a permit m canamutes O t dmc,improve,h Permit
e mit t ri mPdr ed summers
�y Oatkstructure
pd.tois unted pursuant
requires OnApplicantof for sucf the Connwr*.LEcruste a,Lawdsummmt
ggFpa (commencing
cometelkcosNpuntion70thepmvivisionoftheBuinessaimnsessioChapter 9ode)or Sq. Ft. Floor Area Valuation
3g (mmmene xemps,h Section of basis n3 o(theBosinrsa and ProfessionCode)or
that he o assmpt thmefrom and the basis for the digest cumpdan.My violation of $10900
Secdon 7031.3 by arty applicants for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than Eve hundred dolWa(SSW).
❑
1,as me=of the property,a my employees with Mages as their sok computation,
will do the work,and dm muctum is not intended or offered forsake(See.7044,Budneae 35621014 . 00
and Proresion Cade:The Conulimes License Law duce ant apply m an owner of
Required Inspections
property who bullds ser i mpmses theccon,and who does such work himself or due ugh his
Own employees,provided thmauch Improvements arc not intended oraffered formic IL
however,the building or Improvement issold within one year ofmmpledon,the owner.
builder MU have the burden of proving that M did at build or improve ra purpose or
❑i.u t On project of property,,B ones ad conessines with:)sensed mnuctre. te
constrict time nnot (See.n an Business and Pnolessimesry,who Wilds
Code:)Treves lemon.
e ion.Lid ® t` /
censeLaw doosr such plyman itha ofproper(i)lice sedpurrimproOn Comon,and, O
who
encecontacts for such projects withaconusskKU licenced punuammiM Conuaaoh Ot
License taw. (�/(/G
❑lam exempt under Sec. ,Bk PC fa this moan
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby afflno under peoslty of perjury ore of the following dalentions: .
I have and will maintain a Certificate of Consent in self-asum for Wa laces Compen.
inion.as provided for by Sectim 3700 of the TsWr Cada,for the performance of the
wage for which this perme is issued.
❑1 have and will maintain Wastes Compensation Instance,a requital by Section
3700 of the labor Code.for the performance of the work for which this permit Is Issued.
My Workefa Compensadon Imam units end Policy number me:
wrden�PancyNO.: 113-0013�1 oy
CERT( ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
(This section recd notbecompleted Ilde permit Is Intone hundred dollar(SIM)
or lab)
I mniry Out in the paromtauee of dm work for which this permit is around,l shall not
employ arhyperson In any I
ram; mbrrsIM me subject to Workm
er'Compeadon
Laws o(Cdiromis.Dan 1e 1 WCJ�
Applicant
NOTICE TO APPLICA ter mak! thin Cenllimm of Eacmption.You should
became mbjea m Ne WoheYa Compenset an pmvWons of On labor Code,you and
0 Z forthwith comply with such provisions or this permit mall M deemed revoked.
Zti CONSTRUCTION LENDING AGENCY
F" 1 Maly affum that One is•construction lending agency for the Performance of
P4:
the work for which Ws permit Is Issued(Sec,3097,Civ.C.)
W Q Len ices Name
.7 z Luder's Addmn
V Q 1 ceNfy that 1 Mve read this application and num that the show Information is
D. correct I agree to comply with At city and county ordinances and some kws mlating No
building construction,and hereby auNamc mpmeenotiws of this City to enter upon he
W above-mentioned property for inspection purposes.
Ly, (We)agree m save,indemnify and keep hsrmiess the City of Cupertino against
„y y Ilabilides,judgments,cote ad expenses which may in any tiny accrue against said CityIn /r_
V APPLICANTeUNDEof the RSTANDS ANamiOf thisD WILL COMPLY WITH ALL NON-POINT Issued by: Date G
SOURCE RggppuyynRRNSx.
p7ff iSN. 6—►7-OS Re-roofs
Signdum a VContna Dam
HAZARDO S MATERIALS DISCLOSURE Type of Roof
Will the applicant or Put=building aceupanRmse or handle h4acous material
as definN by the Cupertino Municipal Code.Carter 9.12.and irk Health and Safety
Me,Smunn2s33xa)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yin ®Nu
Will the applicant or future building occupant nm equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit herardnns air cnom rinsno an defined by On Bay Arca Air Quality Management all new materials for Inspection.
DiWict7
C]yes ONo
Ihp.redlthe harardnusm 5505. te33 and 55 under Chanter 6.9S ofthe Wilding (9-1
rias n t B Safmyhavec4Sadons at I,i my n spOsib34.1 i ndcnmM th ccup Wilding 7`6
time not currently hots a tenant Net it is my responsibility m notify the occupant of the
to
which mud lx met Prior m iduanm of a CmeBcao or Occupancy. Signat�hWApplicalid Date
Owner or authorised else. Doo All roof coverings to be Class "B"or better
CITY OF CUPERTINO
REROOF d S
�CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: Phone#:
(6,u.\ $eaSer, 4og/314- 1o94
Contractor: Phone#: License #:
Contact: Phone#: Cupertino Business License#:
Se.l� Qc:c� rvw.n 4051�(0�5030
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ■ Asphalt Shingles
0 Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings 3- ❑ Provide I.C.B.O.Report#
e To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
n
Qy_moue ala S ko-ke add Ya"C.O.Y. PI wood 5o c. P(e!. co 301b. Fels
Residential tornmercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are anrestrictions: LJ
Cost of Projept: Type of Construction: Occupancy group:
0 lot) ( e -nooF )Z5Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSETSMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCOF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT# O �I!
M)50 ondo k.
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
VU U
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass% Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing U-$o.uc (Zoog etAoua.\
Septic Tank
Sheet Metal
Sheet Rock
• Tile
dWrk&/Coactor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY�F Telephone: (408)777-3228
UPEf�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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs.rriust have a minimum of r/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: Pw. k SaASen
Job Site Address: - \\3.50 ( -e-ap b C�
Roofing Company Name: ''Te Q; 5c*Ma_^ Q.00qz
Applicants Signature: Date: (o-17'C5'
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper