04080109 77777577,
CITY OF CUPERTINO 5 '" 3 r f '' '�s/'�yyfa��sa��g'�, "�
BUILDING DIVISION PERMIT .�,CO Ty2AC" SOR Ni-,O,R1Y N 0 I ,;
BUILDING ADDRESS: PERMIT NO.
RESPONSIBLE ROOFING INC 04080109
OWNER'S NAME: PERMIT ISSUE DAM
ONE: - SANITARY 0 OL N0.
ARCHITECT'/ENGINEER: - BUILDING PERMIT INFO
BLDG EO PLUOMB MEOCH
Ldp Lien
DECLARATION lobD r !-lLE
1 hereby affirm Ibel 1 em licensed under provisions of Cheerer Y(commencing
with Section 70018.1'Division 3 of the Boninra�Q,d Pmfiesaimex Code,and my rices is
^�� in relyy(.rtqand.(Ufeeect. ✓ 32�`aoia REROOF W/FOAM ROOF "
�Z Licen5a4(ass `I� Lic.d
JJ Dames— 2 Common,
om m n,
, A\ � RCHITECPSDECL ION Z
��ffF tbmat�td my plans shell he used as pummrxnrds `"b� SEP 2UU4
?.0
3GZI Licensed encu ffir 1 BUILDING
3 OWNER-BUILDER DECLARATION
I hereby.Sec Del 11. exempt from the Contractor's o e:Any c Lew for the
E0 O following reason.(Section 7(131.5, t.alter. and Professions Code:Any city or county
$� which requires a Permit re conNuo,applicant
improv,demolish.m repair any statement
Fit prior to its censed pursuant
proappns;of for such Contrarmluoicese Lawtlsammcnt
�Q that he is licensed pursuantmthe provisions;of the Contractors License law(ChePrerY Sq.Ft.Floor Area Valuate ❑
(commenting with Section 7000)of Division 3 of the Business and Professions Code)or
c. $ that he is exempt therefrom and the basis for be alleged exemption.Any vlolauon of
Section 7031.5 by any applicant for a permit subjects be applicant lm a civil penalty of 3tpI 0 0 Occupancy Type
on,more Wan Eve hundred dollars($500).
❑1,as owner ofthe property,or my employees with wages as theirmle compensation,
will do the work,and themoclum is not intended m offered(create(Sec.7061.Business
and Professions Code:The Contractor's License Law does not apply W an owner of Required Inspections
Property who buildsor Improves thereon,and whodoessuchworkhimselfor through his
awn employees,provided that such Improvements are not intended oroffered for sale.If,
however,the building at improvement is sold within one year of completion,the exact-
builder will have the burden of proving that he did not build or improve for purpose of
um.).
❑1,as owner of the properly,am=elusively contracting with licensed contractors in
construct the project(Sec.7044,Business and Prometheus Code:)The Contractor's Li- _
coma taw docs not apply to in owner of property who builds or improves desmon.and
who contracts for such pmkcts wit a contrceor(s)licemed personal to the Contractors
License Law.
❑1 am exempt under Sec. ,B&P C for this recon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby effirm under penalty of perjury one of the fallowing declarations
1 haw and will maintain.CeNfiamaf cmuent to self-insure for WeakerSCompen.
sation,as provided for by Section 3700 of dm labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,at required by Section
3700 of We Labor Code,,for the performance,of the work for which this permit is issued.
My Workers Compensation Insurance carie and Policy number are:
Carie. w Poli f 3
3
ERTIFICAT•OFEXE Pn0 WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Hthe Permit imforosm hundred dollars(SIM)
or less.)
I comfy tat in the performance of the work for which Its permit u issued.l shall not
employ any person in any mannerm as to become subject to We Workers'Compensadon
Laws of California Dam
Applicant
NOTICE TO APPLICANT:If,arm,making this Certificate of Exemption,you aheuld
become subject to We Worker's Compensation provisions of the labor Code.you muss
.J z forthwith comply with such provisions or this permit.h.11 W dermad rewked.
y OCONSTRUCTION LENDING AGENCY
(~ rN. I hereby affirm tat there is a construction lending agency for We Performance of
Qe, � die work for which this permit is issued(Sec.3097.Co.C.)
1270 Lender's Name
a 0 Lender's Address
U C I certify that I have read this application and mare that We above informed..Is
Hcorrect.I agree to comply with all city and county on ind men and areas laws relating m
pU building construction,and hereby asoorim repromnmiws or this city to enter upon the
a above-mentioned properly for iespecdon purposes.
(We,)agree to caw.indemnify and keep harmless We City of Cupertino tui
Nt� IIaldifides.judgmeniscosts and expenses which may in any way see=against said City
f�Z in consequence of the granting of This Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
I
OURCEREGULAT10N5.
„�a�� S'r� e-roofs
nature or ApplianVContrector Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stare orhandlc ha'mdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will We applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hamrdome air cmmminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
Dirric4-
❑Yes ON.
I hese mad the h.rdous materials requimments under Chapter 6.95 of the Califor.
nia Health&SafctyCedc,Seeuons 25505,75533 and 25534.1 undersmod that if dm building
dors not currently have m m nt,oh.at it u my responsibility w nnul'y d¢occupant of the e�/
rcyuircmcn must home prior CcniOcamofIXcupency. �ignatureofApplicant '� Date
- All roof coverings to be Class "B"or better
Owner or amhorizcd agent " Dam
`—f
- Community Development
F 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMITO
O
OWNER'S N PH010#
GENERAL CO CTOR: FAX
I am not using any subcontractors:
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
Septic Tank
Sheet Metal
Sheet Rock
Tile
r —� — ?/Contractor Signature Date
' s
Community Development Department
! Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
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 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: -Vhv1 fznwe
Job Site Address: I86lGn T'1I�n Ave.
Roofing Company Name: R25��4/'�1Sl,oIe 2a0A' nQ 7Qne .
A "1"'
s Signature: a t y ( Date: -1 /20/6+
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO J u
REROOF
I�T °
CUPEINO PERMIT APPLICATION FORM
APN# Date:
Juto 20200`x-•
Building Address:
15NcO A e..
Owner's Name: Phone M.
Mr. v 2s�I- q8
Contractor: Phone#: License#:
C• aeb- 32 8` 10
Contact: Phone#: Cupertino Business License M
fieli (C—V--) -SC18U
Type of Roof Covering:
Existing: Proposed:
3,'13uilt-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) fiY Other(Specify) 1,—Onnn
Number of existing coverings 1 ❑ Provide I.C.B.O.Report#
l9'�To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: Tear o all:spcse ®X i s r) l ✓o . APP ILi At wcam roa
Residential 0' Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are an restrictions: i5
Cost of Project: Type of Construction: OccupancXZroup:
_ ✓ S• r 2
if
a Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
il) ENERGY Energy IBUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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