03070184 CITY OF CUPERTINO '�"
BUILDING DIVISION PERMIT CONTRACTORINFORMATION
nUILDINGADDRESS; SIMON SAYS ROOFING PERMIT NO 03070184
A-7:71 TTTqr)N AVE, I
OWNER'S NAME: 3866 REXWOOD CT PERMITISSUEDATE
ONE: . (408) 531-9700 SANITARY 9 CONTROL NO.
ARCH_ITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MET
0 0 0 0
'200 LICENSED CONTRACTOR'S DECLARATIONUW Job Description
F❑ I hereby affirm That I am If mod under IT Bions of Chapter 9(commencing p
W with Section 7Mfi of Division 3ofthc Businr r}fid Pruhssinm Code,andmylicen¢la
_O� in full fn d Tea J I/
ztgz Licenm ela3!' —" see a >R] l/y RE-ROOF
� Dam cropmArtairwif--- fA�rs— ss �11\�.I/J�,ga l6et9o+1
ARCHI CI'S DECLARATION
Di m \I undc.tanJ my Piens ahali M used As public records
DsJUL 3 0 2003
3 0 n Licensed Pmfcasitiml _
S OWNER-BUILDER DECLARATION
m 1 hereby of[.that 1 am exempt from The Contractors License Law for the
❑O following mason.(Section 103 I.S.Business and Professinns Code:Any city or county 1
x m� which requires a permit to construct,After,improve,demolish,or repair any structure BUILD9 r
Fly Prions I%issuance.also requires the applicant for such Permit o Glc a signed statement
< the,he is licensed pursuant to the provisions of The Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)a(Division J of the Busincas and Profession&Code)or
that he Is exempt therefrom and 0m basis for one alleged exemption.Any violation of 37517033 . 00
Section 7071.5 by any applicant for a permit subjects fee applicant to a civil Penalty of APN Number Occupancy Type
not marc Nan five hundred delta.(S500).
❑I,m cower of the property,or my employees with wages as their sole comPensallon,
will do Ne work.and The structure is not intended or offered fonale(Sec.]We,BusinusReg�ired Ins ec[ions
and Professions Code:The Contmom s License Law docs not apply To an owner of 3 0 7 - I NSULAT ION p
pro any who builds or improves mercon,and who dura such work himsalf orthrough his
Own employ=,provided Nat such improvements are not intended or offered formic,If. 601 — ROOF TEAR OFF
however,the building or improvement is said within am year of completion.Ne nwmn
builder will haw the burden of proving That he did not build or improve fm purpose of 602 - ROOF PLYWOOD NAIL
"le')'El 603 - ROOF BATTENS
1,a owner of ct property,,Business andvely etinuaains with:)TheeC .tract lis to
.am et Neprojoct(Sec.7B,a, norand ny he
Cade:)T7mC tharean.Li.and 604 — ROOF IN—PROGRESS
erne Iso docs not apply m an owner of property who esed p or improv.thereon,and,
who La contracts for projects withaewninnor(q limtued pursuant to Ne CanuaneY&
0
License A.exempt
1 am exempt ander Sec. .B k P C for This moon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby&from under penalty of Perjury am of the following declarations:
I have and will maintain a CenifTeate of Canton to&elf-insure for worker's Compcn.
131"
tion,o provided for by Section 37W of the Labor Code,for the Performance of the
rk for which this Permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for Ne urformame of Ne work for which Nis permit is issued.
orker's Compensation insurance arrior and Policy number1: g�f�r 1111 N Policy No.:CERTIFICATE OF EXEMPTION FROM ERS'
COMPENSATION INSURANCE
(This section need not hccomplcted If the Permit Is for one hundred dollars IS I W)
or less.)
1 cenify that in the Performance of the work for which this Permit is issued,I shall not
employ any ximon In any manner in As in hoemad subject e ifm Worker'Cempensailnn
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should
Mcome subject m the Workers Compensation previsions of the Labor Code,you must
.,O forthwith comply with such provisions or This Permit shall be deemed revoked.
'Z4CONSTRUC ION LENDING AGENCY
'(• (hereby affirm Net Ncre is comtrunint lending agency for use Performance of
R' 7 the work fur which this permit is issued(Sec.3097,Civ.C.)
tg1 Q Lender's Name
4nder's Address
U Q 1 cenify Nall have read This application and sum OUT the above infomwiun is
E„ comet.1 agree to comply with all city and county ordinances and stmc laws relating to
OU building construction.and hereby audition represematiws of Nis city to enter upon Nc
II] ahovomentioned property for inspection purposes.
y (We)agree To save,indemnify and keep harmless the City of Cup rtino against `
G11liabilities,j mcnts,costa and cspcnu&which may In any way cc.c against said City J7
U in cone, ee the gra 'rage Permit.
APPLI NT DE N 1'�D WILL COMPLY WITH ALL ON-POINT Issued by: Date
SOUR R L S.
- -o Re-roofs
5 .,clic of Ap i,,aT/C.mactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hemodous material
As defined by the Cupenine Municipal Code,Chapter 9.11,and the Health and Safety
Code,Second 9Nu
15531(a)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment ordevica which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as dcrned by the Bay Area Air Quality Management all new materials for inspection.
o vict7
❑Yc& �QNn
I have read the hamadms mamriaBmquircimms under Chapter 6.95 ofthe Cahftin
.is HcalAuhm�L
Safety CodeKSc )5,"1�5533 and 15574.1 understand NOT ifdm building
dsrs pdnsinanoatifftrequisumcctifaCcm ca eroompan . Signature of Applicant Date
2 -B All roof coverings to be Class"B"or better
Owncot Date
1,
I
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
*UPEkTINO 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: DO Q A /A ✓) 2-6
Job Site Address: 15? 7 2 l 1 f 1 So q 11-ve
Roofing Company Name:— Ysizoor, 4
A p - 03
licanYs Signature: Date: 7 - > J
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF d
CUP40 1 070/q
PERMIT APPLICATION FORM 3 070/q
APN# Dat . `>
Building Address: C 167 7
AgRop T-1, VC
Owner's Name: Phone#:
0
Contractor: �51nt, yl 5V eoj�Phone#• License#:
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
19�Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles p_ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
X To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
Te-Ar i Rr �- GrAre 1 . LIA-F !f 3o Y2 S 'n
Residential Commercial ❑
Fire Zone: erE]�Nc Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of P ject: Type of o s ti Occupancy group:
Qty.i6
A l c 1e 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