04100176 BUILDING DIVISION u'a"+F ser<,' y,sacs t,r
CITY OF CUPERTINO;:
PERMIT ONTRACT R INF t1Y A FIUIV�
' ern
BUILDING ADDRESS: - "' PERMIT NO.
- COUNTRY ROOFING 0
OLD4100176,.25 '
OWJUAN
NER'S NAME: - .... PERMIT ISSUE DATE. .
IONE: " SANITARY C OL NO. -
ARCHITECTIENGINEER: - BUILOlNO PERMITINFO -
s. BLDG. ELECr PLUMB MECH.
+�oro z - LICENSED CONTRACTOR'S DECLARATION O _
YmF 1 hereby affirm that 1 am Iimnwd under pmvistnna of Chapter 9(commencing - ` .. Job Description. -
<Zl with 5eA t71)gl)oft) isron3of0milmnuesaaod Profeaiom C de, dray, raw is e . .. ,
;EH tnfullforceandeIfc ��a 3� \�
5�� Licenw Cl l� Lie As REROOF W/ COMP.r FII TLED.
nl- Dem Cunlmclar v� r
-e ARC all he S es pm RATION
. y C I undersand my prem shell M mud as public rccnrW
DEC IL 2004
DVIU ',
y�fn Literati Pmfcssional
g OWNER-BUILDER DECLARATION -` _
a O 1 hereby,affirm coati 1. exempt from the Cssions o License Law
y. for the
D D following reason Permit
t ](131.5,Business and Improve.
de Professions Code:Any city ter county _
k$ which rcgmma a permit re miresconstruct,afore i t forsu demolish,or repair any uwmum -
F��n Iprior toM,hei tsiauaomumantquithc hviislomntfeCon Permit Tileesigned satcmcm —
< (commee cing wit pSaLmA to the pmviviom of the a Bu inosa Licaoe lsw(Chnrtm9 ,Sq.Ft.Floor A ValUat On
that he 6 exempt
of Divdiafr the
theeged exemptand ProfMyvicodc)or
y
that io ts exempt ihercfrom and Ne bale for be cts the exemption.An Any it penalty
of
Section than by any applicant for a permit subjects the applicantmacivil penally of - 39100 Occupancy-Type
not mort Nm five hundred dollar($500). _
.. 0 1.az owner of the property,or my employees with wages a Weir sale compensation.
will do thc work,and the structure is notinurded oroffemd forsde(Sec.7044,Busiws Required IDS
Fee tions
and Professions Cade:The Conuacmra Limnx Law dors not apply m an owner of Q P
,. propenywhobuildsorimprom Wv..,andwhodoe .h.,khimalfarNwughhis I- - - -
ownemployms,Provided thatsuch improvements axnot intended oroRered forsale If,
hawevea the building or improvement is sold within one year of completion,the owner.
builder will lave the burden of proving mat he did not build or improve for purpose of -
sale.),
❑I.as owner of the property am exclusively contracting with Ilmnxd contractors m _
construct the project(Sec.7W,Business and Pwf sumps Cade:)The Contractors U. -
whochwdorsnotapplymanownerofpropertywhobuildsorimptoth Centra,And,
whenseI contracts for such projects with acomnemt(a)IicenxdPursuenuo the Contractor's _------- --- ^' -.-' '----------.--
'
License I.
❑IamexemptunderSec. _ ,BSaPCfmthismaon
Owner Data
WORKER'S COMPENSATION DECLARATION -
I hereby anion under pmalty of perjury one of me following decimations:
I have and will maintain A CertiOmmof Oweenuo self-insurc for Workers Compen-
sedan,az provided for by Suction 3700 of the labor Code.for the pcAermanm of the ..
work for which this petmfl is named
❑I have and will maintain Workers Compensation Insurance,As required by Secdon
3700 of We labor Code,for the performance of me work for which this permit is issued. - -
My Worker's Cnm oration Inavanm canner and Policy number am: -
Carrier:
'VTOO OftL( .U -D1ti Policy No.: -
CERTIFICATEOFEXEMPTIONFROMWORKERS' "COMPENSATION INSURANCE -
ME section reed not be completed if the permit is for one hundred dollars(SIM)
or less)
1 certify Not in the perfmccanm of the work for which mia permit is issued,I shall or
employ any person in any manner an az in become subject to the Workers'Coml wadon -
Laws of California.Dam _
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you shoulJ --"" - + .-•
Income subject to the Worker's Compensation provisions of the Labor Code,you must
0 permit forthwith comply with such provisions or this pit shall W deemed mvokcd.
r` CONSTRUCTION LENDING AGENCY
'r+ I hereby affirm mat them is a compaction lending Agency lot me performance of '
lYi > me work for which Ida permit Is issued(Sec.307,Civ.C.) �-"--
131 Q Lemcr's Name,
z Lenders Address,
U Q 1 certify that I have read Wis application and sum met me Above Informuiun u
Ii.F torten.I agree to comply with all city and county ordinances and sista laws miming to
pU building construction.and hereby aumorice representatives of this city to enter Dram the
ria above-mentioned property,for inspection purposes. -
(We)agree In ave,indemnify and keep harmless the City of Cupertino ageimt
nF',a l;7 liabilities,judgment.costs and expcaws,which may in any way ammo against mid City
in consequence of the granting of this Permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
SOU�R��jj REGULATIONS.
((,,�-,,`_Q1inn) / �iA"a /0-314 Re-roofs
Signature of ApplicantrCamo mor Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
Will the applicant or future building occupant score or handle havudous material '
7
az defined by the Cupertino Municipal Code,Chapter 9.12,And the Health and Safety
caJa.Section 35s3xaye
0Y.e ❑'Na All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
(�ldocs
Will me applicant m future building by the Bt use equipment or devices which g
J mil hezaNnus air coaminanu a JCGncJ by me Bay Arca Air Quality Managcmcnt all DCw 1118teCialS TOC IDSpeCtIOD.isuin?
❑Yea1 have mol the haam.mtro trials requirements underChapter 6.95 ofthe Calimr.ia Hcalm&SafetyCodc.Smtiom35.A15,25533 end 25534.1undermaw mat ifthe building not curtemly have a truant that it u my respomibility m notify the mcupent of meqi cnlswhichmust emetpaartoissuanceoraCmtincamofampancy. Signature.ofApplicant Date
'uy
wn toramthorf.cdagent Dam roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
fUPE�TINO
Building Department
JOB ADDRESS: ' #ez// OD l-1("
�as90 Sam -�-�
OWNER'S NAME: PHONE # g- S- 2
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors: De "� /6-j:?-6V
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
er/Contractor Signature Date
act10300
ment Cepa,"_ ent
Budding Dnision
City of Cupertino
Torre avenue
Telephone: (408) =,-32128
*UPCITY
E TiNO Ear: (408) r r-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 an 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: ✓Jq/�,'U C c e15t
Job Site Address: aaS l D Sn� TV%0- A)
Roofing Company Name: O /�r-�, OO I'�
A plicant'sSignatur4- / Date: /0- a6- o��
6k✓uL7tJ�+
. Greg C eel
Building Official
Revised 1/30/03
Panted an Recycled Paper
CITY OF CUPERTINO
aTy � REROOF
UPEkTINO PERMIT APPLICATION RM
FO
WP` # Date:
3ya I � o � � / o -
Buildinz. Address:
�
a6-Ro 3(N ulg (i rzo '�
O t ner's Name: Phone
S� Uc �— ►3c Sem 41
Contractor: Phone #: License #:
Contact: Phone #: Cupertino Business License #:
��- go F F3cc 0 3(P9
Type of Roof Covering:
Existing: Proposed:
7 Built-Up Roof ❑ Built-Up roof
7 Asphalt Shingles Asphalt Shingles
Wood Shakes o Wood Shakes
Wood Shinsles ❑ Wood Shingles
Other(Specif}) ❑ Other (Specify)
Number of existin_coterin2s - t] Protide LC.B.O. Report#
Z) To be Remoted ❑ Provide Mfgr, Installation Specs.
I
,AL
Hage Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
b Description:Kc-_/r7dvt. C--X/6 j iNG (_e,4-I LTL-. (9 r SI-I/t Kra ��11
1 C_L_ S LJ
Residential A Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of project: Type of Construction: Occupancy group:
O 9 D d-z'o.ol= 3
Qty. if
Applic 1 Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDL 1G
BSEISMICOM Seismic Commercial BUILDING
BPLANCH_ K Plan Check Fee BUrLDING
BUSLIC Business License BUILDING
27r, _S_
$ 7