03100056 ;'C'TLDING
ITY OF CUPEWHNO
BUILDING DIVISION PERMIT CONTRACTORANFORMATION ;
ADDRESS: PGRMITN003100056
i
I E.R'S NAME: FERMrI'5SUE DATE
NE: - SANITARY NO. CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
p �Oo LICENSED CONTRACTOR'S DECLARATION
4 u I booby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
t � with ScctionT0lg))nf Division Sof the Busi�Skhd Pmfcuinns Code.end mylicense is /
Nin full forrVd effect. 7[ 7��{G REROOF
Q
,gz Lieenscoasa —39 Lic.x
(
Dan—ContractorCONTRACTOR: BRADSHAW ROOFING
ci Iundcmtan pia .n�be use lDap creood'al"/
L¢ensed 1`101...ost
a 3 OWNER-BUILDER DECLARATION
y p 1 berchy alarm that 1 am exempt from Ne Contractors License Law for the
b�00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
j9 which mqutms a permit to comu ic,,eters improve,demolish,Or¢pair any structure
prior to its issueacc,also tequirea the applicant for such permit to fide a signed statement
�' siso that he is licensed pursuant to the provisions of the Contractor.License Law(Chapter 9 Sq.Ft. Floor Area Valu$tioO500
F (commencing with Section 700(ynf Division 3 nfrhe B usiness and Profession I Codi)or Nat he Is exempt Ihcmftom and Ne basis for the alleged csebandon.Any violation of rf. fcT�eyn w,n
Section 1031,5 by any applicant for a permit subjects the applicant to civil penalty of 39sY19i�Ip161@erOO Occupancy Type
T
not me.than five hundred dollars(M). P Y YP
( ❑1,as owner of the property,Or my employees with wages as their aide compensation,
will do Ne work end the structure is not intended or offered for sale(Sec.]OCA,Business
and Professions Code:The Committers License Law does not apply to an owner of Required Inspections
propeny who builds or improves thereon,and who doessuch work himselfor through his 305 - FRAME
own employees,provided that such improvements are not intended oroRered for sale.If, 307 — INSULATION
however,the building or improvement is sold within aro year of completion,the owner.
holiday will have the burden of proving that he did not build or Improve for purpose of 601 - ROOF TEAR OFF
s1.1. 602 - ROOF PLYWOOD NAIL
{ ❑LasOwner of Iceproperty,sin exclusively contracting with:)TheeCcontractors to
� consumer me pmjca(Sec.7044.Business and Professionscwe:)Tho Contractors Li- 603 — ROOF BATTENS.
q come Law does not apply to an owner of property who Wild&orimproves lhemon,and, 604 — ROOF IN-PROGRESS
9 who contracts for uch projects with a contractor(s)licensed pursuant to the Conuactnrs
License taw.
❑I am exempt under Sea ,B h P C for this msa.a
Owner Data
t WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dalarallom:
I hove and will maintain a Cenifcate of Consent to selfdnsure for Worker's Compcn-
salion,as provided for by Section 3700 of the Labor Code,for the perfmmance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inunnce,'a"hired by Section
3900 of the Labor Code,for the performance of the work far which this permit is issued.
My Worker' Cn pensaI Insusan carticr end Policy numbor am:
4IA�I, Pa No.: I4SNO d�
V CERTIFICATE OF EXEMZ FROM WORKERS'
COMPENSATION INSURANCE
fThb section need not he completed if the Permit is for one hundred dollars($I00)
or loss.)
I certify Out in lie performance of the work for which this permit is issued.l shall nut
employ any person in any manner so as in became subject to the Workeri Compemallon -
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making thio Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Close.you must
�O fnthwi to comply with such provisions or this Permit M deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
I Wrohy allirm that them is a construction lending agency for the perfmm ons,of
La F�-t Ne work fur which this permit is issued(Sec.307,Civ.C.)
zl Q Lender's Name
Lender's Address
Z)z
J Q 1 coolly Nu I have rod this application aW sum that the above information is
y toren.I agree to comply with all city and county ordinances and sole laws relating to
7rJ building constmction,and hereby mahmin reprcsematiws of this city to enter upon the
J+a 'hove-mentioned properly for impaction purposes.
(We)agree to saw.indemnify sad keep humless the City o(Cupcnino against
r fzag liabilities,judgoomm e.sts and c.pa.,which may in any say at.against said City
in
of ffic
J^ APPLICA`NTCUNDERoming of this permit. _0STANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ONS.
/` / /0 73 Re-roofs -
Sc�fApplionVCooinmr Data
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haardous material
at defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
ewe,Splirmen.25532(.)? Nm All 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
it leamous air contaminants u dcrined by the Bay Area Air Quality Management all new materials for inspection.
rivia?
F1 Yea XNo
I have mw the hovatdous materials mquitemens under Chapter 6.95 of the Cali fary
ria Holthgr Safcsy,Cdde,Scetion255115,23577 and 25534.1 undcrsmnd hat i(the building
dam not ctarmody hese a tenm4 that it is my res nsihiltry to nutity the Occupant of the
req mmcnu hmasl lstm prior to its - nf.Ccmficasam Occ panty Signature of Applicant Date
4 ,)QM3
Ow r aupwized.gcm Date All roof coverings to be Class"B"or better
Community Development Department
Building Division
1r City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEkTINO
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: F\ ,F 4h S 1 e n
job Site Address: to 3>\\� 1�C >°G, \L
Roofing Company Name'': 11 .CC OS�.),U )'Lc1 I) 4\ )CQ
A plicanl Signature: L Aljoll l � w�p6t, Date: (0(01 iQ3
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
9,
CITY OF CUPERTINO o 3 ( o
REROOF
C17Y OF
CUPERTINO PERMIT APPLICATION FORM
APN# G O Date: I01( 03
Building Address•
S eQC�. j ( 0j21er+AACD
Owner's Name: Phone#:
K- % h ko%jt h Ho< Z21 -22 11
Contractor Phone#: License#:
c1 v) O
Contact: Phone#: Cupertino Business License#:
(ak \\ a kk) 4 l - 1z ki 7
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
0 Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
RI 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 P e t. if
there are an estrictions:
Cost of Pro' ct: Type of ConsfruAlt' 'n: Occupan
Qty. if
A r le 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
235" �