03060091 ,r CITY OF CUPERTINO
BUILDING DIVISION PERMIT C-0NTRAC,T,QR INFURMATION..
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BUILDING ADDRESS: ......
ERMIT 9003060091
' OWNER'S NAME: P93MIT'a6Wr1L/2003
NE: SANITARY NO. CONTROL NO.
ARCHDECDENGINEER: BUILDING PERMIT INFO
BLDG EIALT PLUMB MECH
300
LICENSED CONTRACTOR'S DECLARATION JobDescription
1 hereby.Man that 1 am Iiavcd under avOf otoo apler 9(communing
with Ser'_7 )of Dhmo.3ofthe Bud Pa(eadou Code.admyIMcueia
n In full rose daffecs,� 2 REROOF
� ice— -��C�ang •-v
3
O ARCHITECTS ARATION CONTRACTOR:CDS CONSTRUCTION
1 understand my Pbu shall ea used AS public rtcords
Lia rated Professional
t, OWNER-BUILDER DECLARATION
I hereby.(Sere that 1 am eumpl sum Ido Cssions Co e:Any c law for the
p o fallowing Mason.(Saito 703 comma Business and Pmfevsiuns Coda:Any city or aunty
$9 which Rquis a a permit to conatrocs,filen,nt pave,demmW,ri repair any tWmun
Z 0 puss m its
issuance,also Rqulra the applicant the Cm permit m fie.Law statement
< (conathum n licewithScsuatadwpmvidonso ofthe trumhLknnselaw(CMpmr9 Sq. Ft. Floor Area Valuation
$ (commencing with Sation 70n d)th basis F r of the a ed exe and on.Any vi ladw ar $12000
dW ea b eumpt thleRfram And the bub for the alleged exemption.Any violatia of
Secdon 7071.5bya"Applicants far.permit tubjeeu Ule applicant an a civil penally of APN Number Occupancy Type
.at more that,Ove hundred dollars(5500).
01,AS owner of the property,or my employers with wages As their tole compensation, 355622009 . 00
will do the work. ad theswnun knee intended a offered for rele(Sec.7014,Business Required Inspections
and Pmfaulou Cade:The Canuscmr's Liaise Law does al apply b ns an owner of 305 - FRAME q P
Property'a'ho Wilds Or imp avec thuean.and who doesSuch work himself.Waugh iia
own employees,provided Not Such improvements art nut Intended or offared fu sale.If. 307 — INSULATION
however,the building or improvement Is Sold within ore you of completion,the owner-
er will have de, en of proving Nat ea did not Wild or improve for purpose of 601 - ROOF TEAR OFF
ASIA')' 602 - ROOF PLYWOOD NAIL
❑1.As owner of the papeny,am exclusively contra ming with licensed canuscton an 603 — ROOF BATTENS
answer live project(Sec.7044.Business And Professions Code:)The Contractor's Lt.
aueLaw doaAnn apply toAn.of ,WnywhoWOdsorhumanness themoe.and. 604 — ROOF IN-PROGRESS
who convects for such pmjects with acontnemos)licensed pursuant be the Contractor's
License Law.
❑lamexemptundersee ,Bd:PCfa Ws Reran
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hCRdY."W under Penally of perjury ane of the following dalantiou: -
Iltsveand willmdnWn.CeniOole ofCouentmselFluurc fa Water'sCanpen-
.tion,u provided far by Section 3700 of the labor Code,fa the pedormaue of
wart for which this permit is issued.
❑1 hove and SIB mainWn Worker's Compen.dan Insurer=, v�quind by SeNort
7700 of on
labor Code.(a Ne Performance of the wart far wall bpemlil is lasuear
My Water's Compewd Insurmexanierud Policynumear 1 #
CERTI A OFEKEMP N RANGE RK S'•F•
COMPENSATION
(Ihb.NarcedutbecanplevAlfdepemdtls Toone du dnllua(SIM)
or low.)
1 Unify that In tiro performance of the work fa which this permit is Issued.I shall not
employ any person in my manner an AS in became subject to the Workers'Compensation
Laws of California.Dare
Applieanl
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you Should
became subject in dse Worker's Commmustion provisions of the Lahor Code,you mut
.,Z, forthwith amply with such pruisians or Nb permit hall ea deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby"no that then it a construction lending agency for Ne performanec of
7d�: the work for which this permit Is issued(Ser.3197,Civ.C.)
Sin Lender's Name
2 Londor'sAdd.
J 0 1 Unify that 1 have toad this application and SUM that tea Shove informWun IS
iL U cartes 1 agree a comply with sit city and county ordinances and stem laws nesting to
0 building construction.and hereby.NonR representatives of this city.enter upon circ
ahoy-mentioned property for iupenian purptux
ie (We).gra So Saw,indemnify ad kap harmless the City of Cupertino against
r 0 liabilities,judgments,costs and expenses which may in my way Sam against add City
J T'i 4 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR�CB�EGULA s.
V/ ti�� Dole Re-roofs
Sign nen p nilCma a manager
�/ Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tea applicant An future building Occupant atop or handle havudou material
AS defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
odea Sectio.zss32(s37 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �J o
Will 0R applicam ar future building occupant=equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hAm Ammar,dr cammemor s u dcOned by the Bay Area Air Quality Management all new materials for inspection.
iaviet7
❑Yes $Nu
r
I have nasi the baurdnas maRnab requirements under Chapter 6.95 of the Califor.
ni.Ha["Sarmyeode,Scctiuu 25505.25533 aJ 25534,I undenbnd that lrum building
does not currently hove a beans,that It 4.my responsibility m andl'y the occupant or W
requirements whk WT:I 'a m ssuance ofs CenlMssaOc-P-5ySigna ureo pp leant ate
�S All roof coverings to be Class"B"or better
Ow nm orimde ant
Dab
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E IST I N O 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 policy on re-roofing.
Homeowner's Name: L%�222 A<'C K,IA.
Job Site Address: SZL!zz 4n/E.", rL-T 4�
Roofing Company Name: ZZ) S le?o2 tft /or✓
A plicanYs Signature: Date: to
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
r CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# O Date:
3 ,-Z- ,
Building Address:cl,
Owner's Name,/ rp Q G1 Ph e#: t�� .
Contractor: H Phone#(:`{ l`•_jJ Li ense
�vso 8 -q1z GBGY /
Con ct: Phone#: Cupertino Business License#:
C E s �/ -
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles �9' Asphalt Shingles
,ff Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
Cl To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
Residential ® Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anrestric ' ns:.
ost roje�` Type of Con n: Occupancy gr
Qty. if
A b 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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