03100206 ,CITY OF CUPERTINO � '� « > A'4 ,
BUILDING DIVISION PERMIT �d000NI TRACT®R INFORMATION
BUILDING ADDRESS: SIM KRAUSE ROOFING PERMITNO03100'206
22999 VOSS AV
OWNER'S NAME: 2310 DIANA AVE PERAUTLSSUEDATE
IGOR KHURGIN 10/29/2003
NE: (408) 779-0704 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;00 rum the,
underSDECLARATION Job Description
fu❑ 1 Mrcby affirm that 1 am licensed under pmvisians of Charter 9 monotone P
�W with BCClloo]QM))al Divi.ionJaf NC Businw eM Prafcssians Code,=nd Jy se"
;ia„ mmnmrce5nderr_ 9 / / r ROOF
>�? License Clas D Lica
a F Date "N h1;Q/G contractor
/ G ARCHITECTS DECLAR me
U 1 undcrsenJ my plans shall he used a public mcnrds ,
,d.O Licensed Pinhad...I
OWNER-BUILDER DECLARATION
y 1 hemhy affirm that I am exempt fru.Ne Connector's License Law for the
p O fallowing mason.(Section 703 1.5,Business and Professions Cade:Any city or county
$an which requires a permit In conandct,alter,improve,demolish,or repair any nruclom $10500
-iy poorto its issuance,alsorequires the applicant(orsuch Permit no file u signedsumment
ez< that he is licensed Pursuan0o the mvinmatof the Cmnecmr''s License Low(Charter 9 Sq.Ft. Floor Area Valuation
iFG (commencing with Section 7000)ofDivision 3 nfthe Business and Prolusions Code)or
$ that he a exempt themfrom and de basis for Bre alleged exemption.Any violation of 34250004 . 00
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number Occupancy Type
not mom than five hundred dollars(S500).
❑I.us owner or the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered fore.].(Sec.7044,Business
and Prormaions Code:The Condector's License Law does not apply no an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
awn employers,provided that such improvements she not intended or offered ror sunk.If.
however,me building or imprcvemant is rola within ore year of completion,the owner.
builder will have the burden or proving mu he did not Wild or improve for purpose of
sale.).
❑1,a. no,or me presently,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Conductor's Li.
cense Law does not apply to an owner of properly who builds or improves thereon.and.
who contracts for such projects with a condacmr(0 licensed marmot to the Conmmoh
License law.
❑ I am exempt under Sec. .B&P C!or this reason
wner Dane
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally or perjury oro of the following declarations:
I have and will maintain a Certificate of Consent to sa f-insum rte Worker]Compere
sW iom.as provided for by Section 3700 of the labor Code,for me performance of the
work far which this permit is issued.
I have and will maintain Wwkefs Compensation Iran==,as required by Section
7110 orthe labor Code,for the performance of the work for which this Permit is issued.
My Worker' nmpemetion Insurance carrier and Policy number am:
Carrier: Policy No:,
CER FICATE OF EKEMWION FROM WORKER '
COMPENSATION INSURANCE
(This section need not becompleo:d if the Permit is for ane hundred dollars(SIM)
.less.)
I ccnily that in the performance of the work for which this permit is issued.I shell not
employ any perean in any manner s,as m become subject o the Worker!Compensation
Laws of California.Data '
Applicant
NOTICE TO APPLICANT:IL after making this Certificate or Exemption,you should
become subject to the Worker's Compensation provisions of the tato Code,you mot
0 ronhwi Or comply with each previsions or this Permit hall be deemed rooked.
Z N CONSTRUCTION LENDING AGENCY
I hereby alibm not them is a construction lending agency for Performance of
x sr7„r Oc work for which[his permin Is issued(Sec.3097 Civ.C.)
LQ Lender's Name
7 z Lender's Address
Q I certify that I have read this application and shale that me shove information is
y come ct.I agree to comply with all city and county ordinances and sum laws relating to
�(J building construction,and hereby authorim mpresentativu of this city to enter upon the
ahovcmentioned property for inspccdon purposes
G (we)agmen to save,indemnify and kc�rp,parmI Ide Coy of Cupertino against
rn liabilities,judgments,costs and expert h M ray way accrue against mid City
7 in consequence of the granting u
dwe
h� APPLICANT U DER T COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE L
Id i Re-roofs
Signsmie Applicanoconsemrate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle havmdous material
as dented by the Cupenino Municipal,Code.Chapter 9.12,and the Health and Safety
ode,Section 35532(0? All roofs shall be inspected nor to an roofing material brain installed.
❑Ye. P P Y g g
Will the applicant or future building occupant use equipment an devices which If a roof is installed with tit rl first obtaining an inspection,I agree to remove
tin harardnus air emmaminnu. nncd by the Bay Area Air Quality Management all new materials.f n.
District?
r-1 Ye. Nu
I have mad the handlous materials requirements under Chaster 6.95 of the Cali for
ria Healm&SafmyCode,Sccgons Y5 62553 and S5J4.l understand thatifdo building , fir
Joes not c randy prole nam itis Pea, oil
m miry(be occupant of the d Z/
mquircho w hon hauaaceoraCertificamar aPeney' Signature o Applicant Date
ie cm Dam
Ownc or shaped. All roof coverings to be Class "B" or better
o
r
Community Development Department
z"m Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
UPEI�TINO
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: L4,A_
Job Site.Address:
Roofing Company Name:
A plicanYs Signature: Date:
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
I
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# ,1 r' Date:
LOA 2A3-
Building
Q3Building Address:
O `
Owner's Name: Phone#:
Contractor: 9 Phone#: License#:
Conta Y Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles t-Asphalt Shingles
e Wood Shakes - ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles X` i.
❑ Other(Specify) ❑ Other(Specify) Z�C
Number of existing coverings ❑ Provide I.C.B.O. Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Descriptio :
Residential 0— Commercial ❑
Fire Zone: Yes ❑ No D' Confirmed with Planning Det. if
there are anrestrictions: LLJJ
Cost roje t, Type of C / Occupancy group:.
Qty. if
AppllqFee 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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