03100139 CITY OF CUPERNNO
BUILDING DIVISION PERMIT r,.cONTRA� TORINFORMATIONg
B UILDINUADORESS: _ WILLIAMS ROOFING PERMIT NO 03100139
OWNER'SNAMEI 4921 CABRILLOPOINT PERNAMISSUEDATE
N@ (408) 252-5120 CONTROL
- SANITARY N0. NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
C= 0 _ (�
10, LICENSED CONTRACTOR'S DECLARATION Job DOSCTIPIIOD
F I hereby offrat Nu 1 am licensed under provisions of Chapter 9(commandng
with Section IMO of Division 3 of NC Business yukRaralcuriont Code,and mylicenub
.oy in full force and cffea
1$? License lace e-3 Lic.R
�iFQqg❑ Date REROOF
Cumrecm FIN
AL®
®
ARCHrIECrS DECLARATION
Iundsund
my,bra shall mused..public retards
5y0 a/S
:dp� Licensed Professional NOV ZUd3
OWNER-BUILDER DECLARATION
)r�I 1 hereby affirm that 1 am exempt(rum[he ConlramDrs License Law for the )
:
00 following reason.(Section 7131.5,Business and Professions Code:Any city or county
5$ which requires a Permit to construct,altar,improv,demolish,of repair any structure
:Z< prions its issuance.also requires the applicant for such Permit to fie a signed statement
(dhathe is licensed punu
ueno the previsions of the Contractor&License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2 $ commencing with Section 7000)of Division 3 of the Business and Profession,Carlo)at
]] at he is exempt thcrefrom and Ne bub for the alleged exemption.Any violation of 36227005 . 00
Section 7031.5 by arryappliant for a pernahubjoets the applicant m a civil penalty of APN Number Occupancy Type
not moa area Bae hundred dollars(S500).
❑I.as owner ofthe pmpcny,or my empioycu with wages u their sole compensation,
will do the work,and life moisture is not intended o,offered for sale(Sec.7044,Business Required Inspections
and Profession Code:The Certificates License law data at apply mean owner Of q p
property who builds or improves thereon,and who does such work hinaulf or Nmugh his
Own employees,provided that such improvements are not intended oroRetod forule.if,
however,Ne building or improvement is sold within one your of completion,the ownao-
builder will new the burden of paving that he did not build or improve for purpose of
ole.).
❑1.as owner of Ne property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Convectors LI.
cense Law data not apply to an owner of property who builds or improves thereon,and
who contracts for such prejeets with a conductorial licensed pursuant o the Carriacou.
LKLnto law.
1 un aempt unit,Seo. .B h P C far this..on
Owner Date
WORKERS COMPENSATION GEC,RATION
1 hereby Num under penalty of perjury ane of the following declarations:
1 have and will maintain a Cenificam of Consent to relf-inmm for Worker's Camper.
7C17100
on,u provided for by Section 3]00 of the labor Cade,for drt performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insvrence,u required by Section
of the labor Code,for the performance of the work for which this permit is joined.
Worker'sCompensationInsurance carrier and Policy nurver. J•^s• {-w`1 Policy No.: Jit_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(]hlsscction need not hecomPleted Ifflat permit ufnfo,re hundred dollars($101()
or less.)
I terrify that in the perfmmanc,of the work far which this Permit is issued.I shall not
employe In any manner so u to become subject to the Workers'Compensation
Laws of Temic.Gals
Applican �J
NOTICE TO APP�LICA vT:1[after making this Cedificete of&emption,you should
became subject m the Worker Compensation provisions or live Labor Code,you must
�p forthwith comply with such provisions or this Permits hell be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby affirm that there is s contraction lending agency or the performance of
x i the work for which this permit is issued(Sec.3097,Civ.C.) -
S1 Alander.Name
3.
z Lcndces Addmoi
..)Q I certify last I have and this application and sus ,that the above information is
L F correct.I agree to comply with all airy and county ordinates and ante laws totaling to
�U building conduction,and hereby authorim representative of this city to order upon the
Y4 'hove-mentioned property for inspection pupmses
(We)agree to save,indemnify and keep harmless the City of Cupertino egainsl
f. Iiabjlider,judgmcros,costs and c mosey which may in any way same against said Ci It,
J w,T7. i sequence of the groming of this permit
PPL CAN,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOURCE RE ATIONS. ww
Re-roofs
Signature of Applicana Comracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the uprisen,or future building acapant stow or handle hada dous material
u defined by the Cupenim Municipal.Code,Chapter 9.13,and the Health and Safety
Cods,Section 35533(B)? _ All roofs shall be inspected prior to any roofing material being installed.
❑Yet
Will the applicant or future building«tupamla:c equipmenlor devices which If a roof is installed without first obtaining an inspection, I agree to remove
it huamous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?
J ❑Yes P)Nu "
&lions toad laehzesrzlous.25505,25533ad255sends,dereanb.95 ifle,Califon /a/ /
niaH reaifrdyifelouccdusmaterialsre3icanic sunderChapndthuiftheCalif.g I 7.° 0
data of currently he amen,that it is my responsibility,m easily the axupant of the
requi nuwhlc at at PdonujssuanccofaCcnifica¢afOIC
�ul y. Signature of Applicant Date
Owner or auth0tizcJ agent Data
/zata
All roof coverings to be Class "B"or better
D
Community Development Department
Building Division
City of Cupertino
7 10300 Torre Avenue
C ' Telephone: (408)777-3228
ITY OFRFCET D Fax: (408) 777-3333
UPE INO
BY u ng 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 " 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:
€13 ?Izalc.ng
Job Site Address: '75'
Roofing Company Name: tl-t-vt>MS
A plicant's Signature: Date: l0 v/°3
• Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
t
CITY OF CUPERTINO p o 3 g
REROOF /
CUPEf� TINO PERMIT APPLICATION FORM
APN# Date:
7j/ I6 2�In3
Building Address:
-7._5 7S ar U! Wa.�cG Wt
Owner's Name: Phone#:
�.irCz �2Kt� S i �o�s - Nyj - �i'sso
Contractor: t Phone#: License#:
I Lt l,Fw,s oo t' ¢03 2S2�SIt u q j 1( � 9 `3
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑1 Asphalt Shingles >C Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs._[L44 6a cr
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Jobcri tion:- W*x- oFc a 1200 (ns tZ xr3ox?r,• cj Inr cu F—tk
"!X-1 CKs.
Residential P51Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plannin a t. if
here are anrest ' do
Cost of Project: Type of Construe ' ccupancy gr
6 t z 10 Rte-Roof{= ' /
Qty. if
A lica e 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
�z �
70