04030041CITY OF CUPERTINO,�,
BUILDING DIVISION PERMIT
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pu1LDINCADDRESS:
V
SIMON SAYS ROOFING
PERMITND04030041
OWNER'S NAME:
PERMIT LSSUE DATE
FRANK B
ONE:
SANITARY N0. CONTROL NO.
(4081531-970()
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Net 1 Boll licensed under provisions of Chapter 9 (commencing
with Section 7(11X)) of Division Sof the Basin uaan Profeastnn. Code,andmylicensei,
in full rorde apt effect. a r C
Cq Lic. p
REROOF
License
Dam - - Comm"..,
T/0 TAR 7 GRAVEL/INSTALL 2 LAYERS MODIFIED BITI
A CHITECI'S DEC T iN
1 umlenum my plans shall W used u publk- cords
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Secuon 703 I.S. Business and Profevsiou Code: Any city nr county
which mgalms A Permit In morWCt. alar, impmvc. demnllRh. nr Rput, rely atNcmm
Sq. Ft. Floor Area
Valua"000
prior to its issuance, also requires the applicant for such Permit o file a signed statement
is licensed m me of the Connector's License Law (Chapter 9
that W Purtuant previsions
(commencing with Section 7000) of Division 3 of Me Business and Profession Code) or
that he is exempt thcmfmm and Ne beau for Ne Alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects Ne applicant m A civil penalty of
not mom than five hundred dollen (5500).
31623096;00
❑ 1, u owner of the prepany, or my employees with wages as their sole compensation,
Required Inspections
will do the work and The structure is not intended muffered (anal. (Ste. 7041. Business
and Professions Cade: The Conamme, Liceme Law rims not apply to an awns, of
property who builds or i m proven themon, Lid who does such work himself or through his
own employees, provided Nataach improvements m not intended oroRemd forule. If,
however. Ne building m improvement is sold within one ray of completion, Ne Owner.'Nasa
NALE
builder will have me burden of proving Net he did not Wild or improve for purpose of
D
ole.).
❑ 1. as Owner of me Property, am exclusively contracting with licensed contractors to
Cade:) The ConvactuLi.
p p�
Ar's
APR 0 2004
construct Ne Project (Sec. 7044, Business and Professions
cense Law does not apply to an owner of property who Wilds or improves themon, and
rS a7C
who contracts for such projects SIN a cora clar(s) licensed punwnt An the Con nictur's
Lie°rase Law.
BUILDING
❑ 1 em exempt under Sec. . B & P C fm Nis moon
OwnerDam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro or Ne following declarations:
I have and will maintain A Cenificam ofCmaAm to sel6invum for Workers Compen.
cation, As provided for by seNon 3700 of the Labor Code, for the perimmanm of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation locurance, as required by Section
'
3700 of the Labor Code, for the Performance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
_.
Camey 1 RTC. g—aiA� ry No.: $zfl>i2�
1k.7_.. CERTIFICATEOFEX NFROM WORKERS'
COMPENSATION INSURANCE
fNuuction need not W compleled lithe pea nk a forone hundred dnllars($1IX)
nr less.)
1 certify than in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as At become subjecumhe Workma CompeoRdon
Laws of California. DAM
Applicant
NOTICE TO APPLICANT: IL atter making this Cenificate of Exemption, you should
became subject to Ne Worker's Compensation previsions or Ne Labor Code, you most
forthwith comply with such provisions or this permit shall W deemed mvoked.
CONSTRUCTION LENDING AGENCY
1 hereby Net mere is lending agency for the Performance of
which s ed (Secti0
' me work for which this permit is issued (Sec. 3097. Cl, CJ
Lenddeers Name
Lenr's Address
1 certify that I have mad this application and Anna that the above infe m ulOP is
' cored. l agree to comply with All tiny and county ordinances and sem laws relating m
building construction, and hereby auNmim mprcmmatims of this tiny to crier upon Ne
above-mentioned property for inspection purposes.
(We) agme m cave. indemnify and keep harmless Mae City or Cupertino against
j Iiabilidea.judgments,casvan xpmucswhichmaylnanyway accrue against aid City
in corse a of the g r this permit.
APPL A UNDE SAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU CE CUL f
Re -roofs
Type Roof
o
Si of Ap c;MVC.nwacmr Date
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant at future building mcupanLSWM orbandle haerdous material
As dcflned by Ne Cupertino Municipal Code, Chapter 9.13, and the Hcallh and Safety
one. Section 255324)?
❑Yoe A No
All roofs shall be inspected prior to any roofing material being Installed.
a roof is installed without first obtaining an inspection, I agree to remove
Will the app cant or Treem Wading Occupant n equipment or d vieex which
mit hawdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for in tion.
Disuicn7
❑Yes No
A,
2
I have mad Ne ham Ins materials requirements under Chaparii.9S offm Califor.
niatio.im ctyCodc, Smumu25505. 35533 end 25534.1 undcrsmnd Nmiflhc building
O
des narte ly a tenant Mut it is my responsibility to notify the om.pant of the
re ire cram h' rile met prior m issuance of a Ccnincam of Occupin
-
S nature Applicant Date
All roof coverings to be Class "B" or better
Owcar authod'red agent Dam
Community Development
10300 Torre Avenue
�}
aClOF
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
�UPEkTINO,
Building Department
JOB ADDS: PERMIT # O
o S4eve S
OWNER'S NAME -5-1" PHO £fc8 S 3 10
GENERAL CONTRACTOR: FAX #
I am not using any subcontractor
Signature Date
Please check annhcable subcontractors and comnlptp the fnllnwino- infnrma+inn-
•mac
t/ Date
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
il
•mac
t/ Date
1 I
Community Development Department
Building Division
f City of Cupertino)
10300 Torre Avenue
' Telephone: (408) 777-3228
(QTY OF
qUPEkTINO 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.
Homeowner's Name: FrA n 14 61,N040
Job Site Address: a 00&S S'+cy&ns crit level
Roofing Company Name: S r M o r S 4 o o 4 "?
A plicant's Signature: Date: - / S O y
Greg teel
Building Official.
Revised 1/30/03
Printed on Recycled Paper
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CToo
CUPER INO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
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APN
#3, � Z3 ��,/
Bldg Permit Fees
BUILDING
Date:
Building Address:
06 to
teveo
C rlee I
Owner's Name:
BUILDING
BSEISMICOM
Phone #:
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
Contractor:Phone
#:
BUILDING
License #:
S R ova'
& 3
%8
Contact:
Phork #:
Cupertino Business License #:
t
0
Type of Roof Covering:
Existing:
Proposed:
Built -Up Roof
k Built -Up roof '
❑ Asphalt Shingles
❑ Asphalt Shingles
❑ Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings )
❑ Provide I.C.B.O. Report #
$i To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu
ertino's Tear Off Policy: ❑
Job Description:_
Ar o
Ta/' d- 6Pgve
'4 f /l La,yecS vnal,' Pel b,
Residential ❑
Commercial [
Fire Zone: Yes ❑ No ❑
Confirmed with Plann' e t. if
there are any re 'ctions:
Cost of Project:
Type of Cofis—trLdo
. ' Occupancy 0oupC
Qt if 1
A )I cabl8 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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