04080186 CITY OF CUPERTINO r. ' +=�c� .$ = a'b" ''`��+ `T�'' ' `'.
BUILDING DIVISION PERMIT �CONTRACTURINFORMATION':
tel = .x&«fin.. .. av`? s x ,%_ u�drt ^I GIS.
BUILDING ADDRESS: DAN ELLIOTT' S ROOFING CO PeRMrr No.04080186
1 '17 STRR12TRONASE IAN
+ OWNER'S NAME: PERMIT ISSUE DATE
7CH'=TnC"rFNGIcNEER'
SANITARY 0 OL NO,
AEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Y00ENSED CGNrRACTOWS DECLARATIONra,hat l em litciucd� r pmvitioiu of Chepmr 9(commcncing JOb D05C i�tA ,ALED
wiDivision Sof thc BUJ' end prnfessiom o@.and mylicenm in '�V■in . z5mie, co irsmnr REROOF W/ ELKE PONE
0 ARC ITECTSD A IDN AUU (4 2�U4
�i 1 undersand my plans aha11 be used as lie reenrW U ��II L -
0 777
G Llecnrd Professional
OWNER-BUILDER DECLARATION
B U IL D I N G
I 1 hcmhy affirm than 1 am"Until from the RATION License Law for the
02 following mason.(Section 7031.5,Bualrow arofas
nd Psiuns Code:Any city or county
$�i which requires a Permit to conswcs,alter,impmw,dcmollsh,or repair my swnum 20
Fto poor N is ismanCCJIW mgWfes ole applicant for Much Permit In Ne a signed saenrom
jthat he is licensedp..arttoWeIMIMIo.Mthe CantmcmrlLicantsLaw(Chapter 9 Sq.Ft.Floor Area Valuation
Us (commcncing with Section 7")of Division 3 ofthc Business and Professions Cwk)or
$ Nat h u exempt therefrom and the bads for the alleged exemption.My violation of �n
Section 7031.5 by any applicant fora permit subjects the appllcam w a civil penalty of 3 9915 MIMWT 0 0 Occupancy
not more Nen Bw hundred dollars(5500). p y��
❑'l.As owner of the property,or my employees with wages u their sole compen utlon,
will the We wok,and tit structure is not intended or offered for sale(See 7044.Business
and Profesum.Cade:The ConuMus'.License law,duct Out apply to an owner of Required Inspections
property who builds or impromfloo en,and who doessuchwork himselfor though hit
awn employees,provided Owsuch improvements am notinentleE or offered rorssla IL
hawewn the building or improwmem Is sold within one year of completion.the owmr.
builder will have the hrden of proving that h did not build or improve for p npose of
talc.).
0 I.as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Cade:)The ConuacterS U.
cents law does not apply to an owner of property who holds or boisterous Wetton,and,
who contracts for such projects with a comtmtorod licensed pursuam to the ConuactoYs
License Law.
l atn ascmpn under S.C. ,B&PC f.this.mon
Owner Dae
WORKERS COMPBNSATION DECLARATION
I herby eDbm under penalty of perjury one of the fallowing declarations:
I have and will maintain a CaNOe caof Consent a u
self-im m for Workere
ces Comp
¢tion,u provided for by Section 3700 of the labor Code,far We performance of the
wort for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of We Labor Code.for thea performance of the work for which this permit is Issued.
M War y` tion Lurs.ecamn antl Polic m em:
Catneq Jm3 Policy /O.7f�I
✓ CERTIFICATE OF MEMPION FR ORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the permit is for one hundred dolltra(Slll()
or less.)
I terrify tat in the performance of We work for which this Permit is himcd,I shall not
employ any person in my rummers As to become subject o tie Workeri CompnuNon
Laws of California.Dace
Applicant
NOPICE TO APPLICANT:If,after making this Cmilicae of Eacmplion,you should
become subject to the Workcta Compc.ation previsions of We Tabor COM,you must
QQdimv
fowith comply with such provisions or this Permit mail h deemed nked.
"•' CONSTRUCTION LENDING AGENCY
1 hereby affirm that Wert is a construction lending agency Int the performance of
a. the wink run which this permit u issued(Sec.3097.Ci,C.)
Ill A lender's Name
= z Lender's Address
U I certify that 1 have read this application a d soon that the above information is
correct.I agree to comply with all city and county ordinances and state laws mlating to
DU building construction,and hereby authonte repmmnadws of this city In enter upon the
r 4 above-mentioned property for millstone PUP L
(We)agree to taw,indemnify and keep homeless;the City of Cupertino against
rh Ilabilides.judgments,cost mit.pe.es which mayin my way..also.,said City
U.Z in corooquence of the Stenting of this Permit.
" APPLICANT UNDE A S AND LL PLY WIWITH ALL NON-POINT Issued by: Date
OUR REGU ro9"y
Re-roofs
signature of Applicant/Contnctor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building occupant store of Modic hrudous material
as dc0ned by de,Cupenin0 Municipal Code,Chapter 9.12,and the HW W and Safety
ode.Scctiez5s3z(a)7
❑Yest 4..1Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant olrulum building Occupant um equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazodnus air contaminants as defined by the Bay Area Air Quality Managcmcm all new materials for inspection.
Disuin7 fy�+
❑Yes �]Nu
I how mad We ht mus, this requirement under Chapter 6.95 of the Califor.
nit Hmith&SnfetyCode,Secdo.25505,25533mdM34.luntknandthatifthe Wilding -
doesno cumend ..AM Wet it is my rell omihility w nndl'y LW nccupm1 fir the
di MIC IpriorwismanccoraC .eofucuPan ignatureofApplicant Date
0ter or autharircd agent etc All roof coverings to be Class"B"or better
Community Development
- 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
aft
CITY OF Fax(408)777-3333
UPEkTINO
Building De art e
JOB ADD E / PEUht # 0�
! 42
OWNER'S N B PHO _ 7 6
GENERAL CONTRACTOR: E!/ FAX #
I am not using any subcontractors: S • a o '0
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 / t
Septic Tank
Sheet Metal
Sheet Rock
Tile
J
Contractor Signature ate
t
Community Development Department
Building Division
City of Cupertino
O + 10300 Torre Avenue
I CITY OF Telephone: (408) 777-3228
L U P E kT I I VAA''O 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 /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: Y ► l•j �� Q r ���� ��
Job Site Address:
Roofing Company Name: D p.� uI t a s
A plicant's S�ig�nature:
Date: c' —20—0
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY ORFECR oF
ERTINO
o� a d
CUPEwo kTINO PERMIT APPLICATION FORM
A
P �( o� Z� Date:
Address:
13'1 �� ee �ec�lv�s CU ec ���
Name:
Phone#.-
Contractor:
:
r: 13`3 --I (�9
nLicense#-
n � ltPS�-t—�?j2� 1Q1�SU
Av� o r V 1S e_ 55q#`13 Z1 Cupertino Business License#:
Type of Roof Covering:
ilt-Up Roof Proposed:
halt Shingles ❑ Built-Up roof
ood Shakes 0 Asphalt Shingles
❑ Wood Shingles ❑ Wood Shakes
❑ Other(Specify) ❑ Wood Shingles
Number of existing coverings ❑ Other(Specify)
❑ To be Removed ❑ Provide I.C.B.O.Report#_t5L4 i
❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will 211121Y With Cu ertino's Tear Off Policy:
Job Description: N-UV\- o, �y -6'^
1.�s{a11 EC1c post= S wHngo ��ns 1 30
1-Ia ALL tJ F W Ft-P�S}}
Residential tqtJ
Commercial �]
Fire Zone: Yes ❑ No �
Confirmed with Planning Dept. if
Cost of Project: there are an restrictions: LJ
Type of Construction: Occupancy cup. ^
l(J rarn� Slh arr��
Qty. t
A 1'>Sa Fee ID
BPERMFEE Fee Detion Fee Group
Bld Permit Feess
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
BUILDING
z4 7 �
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