04100097 CITY OF CUPERTINO
BUILDING DIVISION PERMIT "aC0NT12ACT0R INFORMATION
BUILDING ADDRESS: PERMIT N®4100097
1513 TERRACE D
OWNER'S NAME: PERMIT ISSUE DATE
KENNETH CULBERTSON 10/14/2004
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SANITARY NO, CONTROL NO,
ARCHITECrsENGINEER; BUILDING PLRMRIN to
BLDG ELECT PLUMB MECfI
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LICENSEDCONTRACfOR'S DECLARATION
F I hereby affirmm thatIM1m I am li¢"Con un er provisions nrChapter Y(commencing Job Description
`uS with Section 70M, fDlvision 3 or NC Businc. dp,'an ions Code.and my license is
_ a Inrull m anti ec 7 REROOF W/ SHINGLES
,qz Licca✓ : meg CONTRACTOR: VONCO
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�Y! � � ARCHITECTS OECLIROTords
Y dcrsund my plans shall he ucd es pts rsffcnrda
DyU
0 Licensed Professional
3 OWNER-BUILDER DECLARATION
0 0 1 hereby affirm on 1 am exempt from the Contractor's License taw for @c
o O following massa, ennot t ]o LS,Business and ve demolish,
Code:Any city or musty
$ which myosins a permit to uiras the
alter,improve,demolish,ri mpmr any meuaum
HZa that heor itscensedp pursualso nt
to the@capplimnf for such permit Blcasigned xmmment
(commecingwiit pursuant to the of Division
of othe(the B sinessnd (Chapter 9 Sq.Ft. Floor Area Valu4glg 50
�m (eat he
(commencingwith
erefro]andfir Divisionr th lite Business and Profusions Code)or
�
that he is exempt therefrom roti the bash for the alleged Gumption.Any violation of
Section]031.5 by any applicant for a Penn it subjects the applicant m a civil Penalty Of APN Number Occupancy Type
he,mnremanliehundred dollars(s5oo). 35620011 . 00 p y YP
❑1,u owner of the property,or my employees with wages u their sole econsmatinn,
will do the work,and Ne smuaum is not intended or offered for sale(Sec.7014,Businus
and Professions Code:The Contractor's License law does not apply to an owner or Required.Inspections
propeny who builds or improves thereon,and who does such work himself or through his
awn employcu,provided thatsuch improvements are not intended oroRered forsale.If,
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
safest.
❑1.as owner of the properly,.B exclusively contracting with licensed ntranemm t.
E]1.as the project(Scop]614,Business and Pontracou Cade:)The d commis to
came Low does not apply to an owner of property who builds Or impmversherton.and. ^
who contracts for such projects with a contractor(s)licensed pursuant to Ne Contractor) e�-vM�l
XLcase Law.
Use
am exempt under Sec. .B&P C for this maven
Owner - Dam nFr, 1004
WORKER'S COMPENSATION DECLARATION
l hereby of sat under Penalty of perjury one of the following declarations: ryp Q'r�
❑I have and will maintain a CcniBwte of Consent to sel6iuum for Worker's Compcn-
caork tion,ss provided for by Section 3]00 of the labor Code,for the performance of the .,y
wfor which this permit is issued. as
1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Lam,Code,for the performance of the work for which this permit is issued.
My Worker's Cnmpemation Insurance easier and Policy number aa:
Cartier: P-RmU'�F^.: _
CERTIFICATE OF EXEMPfIQyFROM WORKERS'
COMPENSATIONI SURANCE
(This section need not he completed it the Permit is Of one hundred dollars(Strip)
or leas.)
I certify that in theperformance of the work for which this permit is issoed,1 shall not
en
employs n ni anyVMunnersoasmbecomcsubj st the Workcm'Compnnaatian
Laws of —
Applic �(
NOTI APPLICANT:If,after making this Ccnilicarc or Exemption.you shoulJ
become hjeci to the Worker's Compensation provisions Of the labor Code,you mut
.J Z fonhwith comply with such provisions or this permit shall he deemed invoked.
z CONSTRUCTION LENDING AGENCY
(~ Ifhereby whichaffirm thin there issued Sea.3097,
agency lnnhc perfmmancc of
a Le work far which this permis is issued(Sec.71Y)],Civ.C.)
tat 0 Lender's Name
=z Under Address
V 0 1 certify that 1 have read this application and sum that Oc above information is
(y — Cortic.1 agree to comply with all city and county ordinances and state lows relating to
ii-pbuilding consuuction,and hereby amhorim representatives of for city to enter upon the
} U above mentioned pmPeny for Inspection purposes.
(We)agree to save,indemnify and trop harmleu the City of Cupcnine against
rF'—r N liabilities,judgmcon,costs and expenses which may in any way accede against n!'Ci
UZ to consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMe6X WITH ALL NON-POINT Issued by: Date
ULATIONS. �
Re-roofs
gnasure ofApplicaCZARDOUS Date
MATERIALS DISCLOSURE •
HAType of Roof
Will the applicant Or fmure building occupant store or handle haarduus material
Us defined by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
Code Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yu �tu
Will the applicant or future building oecupam use equip end or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaaNnux air comiminanta as dctincd by the Bay Arca Air Quality Management all new materials for inspection.
Dismia? J.
❑Ycs� alt No
I have mad thc haaNeus materials requirements under Chvpmr695 of the Califor-
niaHcnith&5afcty Cnde.Scctions25W5,25533ond25534.1 understand thmif Ne Wilding
Coca
no,cunently bare a Pasant,of(Orion;is my res msiM1illty m nntily the oecupant of the
a whichmust la;mmryior to Us a facemrcampf0ceupnmy. Signature of Applicant Date
q All roof coverings to be Class "B'y better
Owner ser authorircd agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRE ' . . PERMIT #
OWNER'S NAME PHONE
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors-Om 0,,A&a �
Signature Date
Please check applicable subcontractors and complete the following information:
61 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
Tile
L1 w
�j6q !/Contractor Signature 'Date
Community Development Department
Building Division
City of Cupertino
Dj 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
R'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 mini*num 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 Napee:
" Job Site Addresses d \ S�3 '[ '0.�AQE "CSO.
Roofing Company Nam:
A plicanYs Signature.�� M� Dated
iGreg eel
Building Official
Revised 1/30/03 ,
Printed on Recycled Paper
CITY OF CUPERTINO
` REROOF
�CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
\rzl- k OA
Building Address:
\ ra -T Snck
Owner's Name: Phone#:
NA
Contractor: Phone#: License#:
X10 - \ 4 4 11BI
Contact: Phone#: Cupertino Business License#:
0 I -7 4 6
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ; 0� Asphalt Shingles
Wood Shakes ❑ Wood Shakes
D Wood Shingles - - - ❑ Wood Shingles
D Other(Specify) ❑ Other(Specify)
Number of existing coverings _ ❑ Provide I.C.B.O.Report#
6 To be Removed ❑ Provide Mfgr.Installation Specs.
'P.-Iave Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
"9*rL\N%,bQT.
Residential -Jg�- A::Commercial -M-
Fire
❑-Fire Zone: Yes ❑ No ❑ Confirmed with Pl De I. if
there are any re tions:
Cost of Project: Type of Co o Occupancy
�
Qty if
QA lic 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
2751