04100158CITY OF CUPERTINO'
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BUILDING DIVISION PERMIT�dR,..'.^"-
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BUILDING ADDRESS: ,.
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PERMITNO.
R E ROOFING & CONSTRUCTION
INC 04100158
OWNER'S AME:G9FIEEB BR
PCRMTf ISSUB DATE
ONE: - .
SANITARY OL NO.
ARCHITECnENGINEER:
BUILDING PERMITINFO
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BLDG ELECT PLUMB MECH
t� 0 0 0
'•' LICENSED CONTRACT'OR'S DECLARATION
Job DCSCTIpGOD '
',
1 hereby a(fis Chet 1 am lice ntler provisions of Cbepur Y (rommencing
with 5 tion 70I11).l Dwhion 3.17M q Bupneuand Profcsi um Code, and my license is
in ful tame ad. t. 1/
License as 'IP1 uc.I �7��
REROOF W/ASPHALT SHINGLES
Dhu 1— Condition )4-JLX;st--,r7�-']
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ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
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I hereby amrm Nat 1am from the License Law for me
1..Bumps
toad o :
and oli Code: Any city m county
following moss. (Section Tons
-
r t, altoes
improve. de arta
loll Improve,h any stroclustatement
es, vs
Perlinmolish,
fireadcl,aper,
a signedr
prior m its issuance, also mqo the the applicant for Coli Permit Ne signed stammem
prior itsisssnce, Oil
Sq. Ft. Floor Are Valu
That he islicensedwit pursuant to uuteh LkcnseLaw
of talceBusiness
of Deiou
Cntle)tar
(commencing with Suttonnand) ndons Code) or
Division3 of theexempton,
Any of
M Any
that io U exempt therefrom and Ne baso for the cxemant
,p pp7,ty��r� r�
r00
Occu ane e
Occupancy 'ryp
Malleged
subjects to it penalty
Sous applicant fora posit subjecu me applicant m e civil penalty of
not mom than tiro hundred dollars (i5m).
than five hundred
3Mi (3bl"•
NOV..7
2004
Property. m mY with wegea u
❑i.L es Owerk,
Tppy ��Pr��r �� r., ♦♦♦��'a��s .-, -
atimaneeA
and .Is (Se .7W. Business
will dothework end ft
•and
not apply tooan ow
Code: The Conmanmra License Lew does not apply lf an owner of
: The onuceamm is License L w do
^ -y�
enywin,Proleassiobat mveachereoe,antlwhodaenaucbendedomfferedhmughhia
{Dj
own employers,pmvidctl Nm such improvements arc not intended orogercd for We.IL
ownenywyces,pdovided
LSV\ '\v,
-
however, Ne building or improvement is sold within one year of completion, the owner -
builder will have Ne burden of proving sent he did not build or Improve for purpose, of
sales).
❑ 1, u owner of the property, am exclusively commuting with licensed contractors to
construct the pmject (Su. 70", Business and Pmresalons Code:) The Contractor's U.
come law does not apply to an owner of property who builds or improv thercon, and
who contacts; for such projecu with a conlacmrtU licensed pursuant to Ne Contortive,
-
License Law.
O l em exempt under Sec. ,B&PC for this mason
Owner Data
W ORKEWS COMPENSATION DECLARATION
I hereby encs under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -Insure for Workers Compen-
sation, u provided far by Section 37M of the labor Cade, for tale performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, a required by Section
'
3700 Of Ne labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensationf llasursnce caricr and Policy number are: a,
Cartier.R)t�lll PoIry Na.:l��0
CERTIFlCATE OF E&PI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed irthe Permit is fsone hundreddmllam ($100)
or less.)
I certify that in the performance of the work for Which this Permit is leased, I shell not
employ any person in any manner so as to become subject to the Workeri Cumpensauon
- Lawes of CaliforNa Data
'
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
become subject to the Workers Compensation provisions or the Labor Code, you must
forthwith comply with such previsions or this per til shall be doc red revoked.
I
CONSTRUC71ON LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the perfomume of
Me walk for which this permit is issued (See. 3097, Civ. C.)
Lenders Name
Lendefs Add.
j I ccnify that I have read this application and sate met the above information is
cored. I agree to comply with all city and county ordinances and stale lawn relating to
building construction. and hereby autbo ire representatives of this city to enter upon me
above-mcnuoned property for inspection purposes
(We) agree to siva, indemnify and keep harmless the City of Cupertino ageimt
j Ilabilides,judgments, casts and expenses which may in any way stoma against said City
in consequence of the of this
(-�
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CY
4
granting Permit.
t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date !//
SOUR E
Re -roofs
Type Of ROOF
L Signelurc of<an
AppliVCon Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building uccupantetarc or handle hvardous maurial
"defined by the Cupar in Muni al Code. Chapter 9.12, and du Health end Safety
Co de, Section 255320)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes tousling
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or uOccupant use equipment or devices which
,
mit hazardous air conteminanu .fined by me Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yes u
(have mad thchvaNnuxmaurialsmquimmcnu under Chepmr GYS oath. Califnry
ria Hcnith&Safety Codc.Suuona25505,25533and25534.Iundcrstandthmifthc Wilding
U/ Z O)
2
data not curmmly have a unt nt that It It my responsibility as noul'y the mmisent of me
_ _ `/
rcyuim cLmaatme,a r ;ssaanaar slfcamofOmmuscy.
/Df2
Signatu of Applicant Date
' ' All roof coverings to be Class or better
owner araatharized ,sant
CITY 0,
�UPEt�TINO
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: I Z
Sca [l L 9
R
RMIT # p j0()
OWNER'S NAME: ,ToCt
o L K
PHONE # 4 uk - 6 26 -q 3 Z(D
GENERAL CONTRACTOR:
L RaN ,u
FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following infnrmatinn-
0
ate
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 - LAt - -
U VVl M C_
Septic Tank
Sheet Metal
Sheet Rock
Tile
0
ate
fl &7
CITY OF
UPEkTINO.
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
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.
1V
Homeowner's Name: ��tti V 0 L f
Job Site Address: z(1� I Z J,Co f I (fW 1
Roofing
A plicar
tGreg C�eel
Building Official
Revised 1/30/03
Printed an Recycled Paper
Date: L�I0�
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CITY OF CUPERTINO
REROOF ts�
PERMIT APPLICATION FORM
APN # 3 t / o /
Bldg Permit Fees
Date: Ib
1 -}
Building Address: U I z
%
BUILDING
Owner's Name:/.
�u2 WOLI-
BUILDING
Phone #: G
q 2r72
Contractor:
Phone#:
4(A -La -93z (7
License #:
Contact:
Phone #:
(026-8320
Cupertino Business License #:
Business License
qb -
2 t5
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
❑ Asphalt Shingles
Wood Shakes
3iK- Wood Shakes
Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings 2
❑ Provide I.C.B.O. Report #
To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:1�eMovts
t-2 L -Am t -S Ij�- SNAKE G\& -A- SRtn,lffi,ks, IvSr �-
NUuj
112" CDX /kS'PH/ki SH4N
Residential Coinmercial
❑
Fire Zone: Yes ❑ No ❑
Confirmed with P mng Dept. if
there are anstrictions: IJ
Cost of Project
Type of Construction:',Occupancyou
15006,"
3o
Qty,
Anniida a 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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