03020029 i. CITY OF CUPEWI'INO si2ss8s int: ,�?
BUILDING DIVISION PERMIT CONTRACTORANFORMATION
v BUILDINGADDRESS: R A CONSTRUCTION PERMIT No.
809 ROSE BLOSSOM
OWNER'S NAME 559 CAMPBELL TECH PARKWAY APPLICATION SUR DATE
hk JEAN AW 02/07/2003
TONE: (408) 369-9921 SANITARY NO. CONTROL NO.
ARCHUGE.0 IENGINEHR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
!Oo LICENSED CONTRACTOR'S DECLARATION
� P 1 hereby affirm that l am licensed under provisions Of Chapter 9(commencing Job Description
<i wrth Secion 7(lm)nf DivisionlOf the Busine and Professions Crile.ane
in Lill force am�clf '�0 REROOF
zog: License class 's 1.ic.x x �'p.��^®
O Date �,-�a Cu r r_ N C
�^4- MRLMITECTItll!OLARATI]N
aSy z 1 understand my plans shall W used as public records
ad FEB 14 2003
1-LL C Licensed Pndcssional
Wy OWNER-BUILDER DECLARATION
u<P I hereby affirm that I em exempt from the Contractor's License law for the BUILDING
of
—20 following mason.(Section 703 1.5,Business and Professions Code:Any city Or county
m a' which requires a permit m construct.alter,improve,demolish,or repair any structure
an tion,to its issuance,also"dims the applicant for such permit to rile a signed statement
that he is liccned pursuum In he provismmof the Contractors License Law(Chapter 9 Sq. Ft. Floor Area $O"Otion
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y $ that he is exempt lhemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the Split email to a civil penalty of 3 54"aQ"orO 0 Occupancy Type
not more than five hundred dolhn(S50). P Y YP
❑ Las owner of the propcny,ser my empluyeu with wages az their sale compensation,
will do the work,and the structure is not intended Or Offered for sale(See.7BW,Business
and professions Code:The Conuanor's License law does not apply m an owner of 307 - INSULA'.LTWd Inspections
property who builds or improves Nerem,and who does such work himselforthrough his
Own employees,provided that such improvements are not intended or offered for sale.If. 601 — ROOF TEAR OFF
however,the building or improvement is said within one year of completion,the owner-
builder will have the burden of proving Nat he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
ask,)' 603 - ROOF BATTENS
❑1,as owner of the property,am exclusively contracting with licensed commetora to 604 - ROOF IN-PROGRESS
construct the project(Sec.7o ,Business and Professions Code:)The Contractor's Li
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractnr(s)licensed pursuant to the Cornmelor's
License Law.
❑Inn exempt under Sec. ,B&P C for this reason
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 herchy affirm under penalty of perjury one of the following declensions:
I hive and will maintain.Cer ificam mConsent to self-imare for Wmkerh Compete
sation,as provided for by Section 370)of the Labor Code,for the performance of the
work for which this permit is issued
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work(tar which this permit is issued.
My`WorkeTs Co ti).4sum carr�ieer.: Puryn are'
Camy� r LPoli .:
CERTIFICATE PEXEMPTI FROMWORK'RS'
COMPENSATION INSURANCE
(This section need not W completed little permit is(more hundred dollars(SIM)
Or Car.)
I cenily that in the perfm Orem.of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become&Objec00 the Workers'Compensation
L.Ws of GaB(mnis.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
hecnme subject du the Worker's Cium ensminn provi.siuns of the Ls Wr Code,you hand
OZ forthwith comply with such provisions tar ibis permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
1 herchy affirm that there is a conmmetion lending agency for the performance of
6i the work for which this permit is issued(See.J(y)],Co,C.)
aQ Lender's Name
z Lender'sAddress
U 0 1 certify thal I have read this application and state that the above information is
P correct,1 agree to comply wit all city and county ordinances and state laws relating m
Q U building construction,and hereby authndse representatives of this city to enter upon the
lT1 above-mentioned property for inspection purposes. /
6. (We)agree to save,indemnify and kap harmless the City of Cupertino against
F' N liabilities,judgmeno,costs and expenses which may i n any way ecenO against soil City
U Z in consequence of the granting 9f this permit.
'—'
APPLWXW*0rNDERSTASDS AND WILL COMPLY WITII LL NONPOINT Issued by: Date
OUR
-d Re-roofs
Signora yApplirmiVCummctm Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will die applicant or future building Occupant store or handle hamrdous material
as defined by the Cupertino Municipal Code,Chapter 9.17,and the Health and Safety
Code,Section 25532(a)?
[DY. roofs shall be inspected prior to any roofing material being 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
emit hanodous air contaminants as defined by the Ray Area Air Quality Management all new materials f 'nspection.
District?
❑Yes
I have read the hazard))us materials requirements under Chapter 6.95 of the Califnry
a Health&Safety Code,Se[dons23505,2553J and 25531.1 understand that if he Wilding
Ocx not emn,mly have a dc'num,Nm it is my res(mnsi hit ity m mtil)the oecupant of the
myui`mentsw' uvWmctpriormissuamem'.ccniHeateorXlmwy/7aa naturfApplicant Dale
owreatirrounhurixed agent Dare All roof coverings to be Class "B" or better
a0- _W_W Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
CU PEkTINO
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: Q/� 22,
Job Site Address: 9 /�0 5/�
Roofing Company Name:
A plicant's Signature: 1) _ 7 —v s
Greg teel .
Building Official
Revised 1/30/03
Printed on Recycled Paper