04070075 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CONTRAG-TOR^INFORMATION
BUILDING ADDRESS: T D ROOFING PERM""°04070075 -
OW NER'S NAME: PERMIT LSUEDATE
HAVI NA D
31,113: SANITARYNO. CONTROL NO.
(408) 892-8872
ARCHITECTIENGINEER: BUILDING PERMIT INFO
/A I BLDG ELECT PLUMB MOECH
01 o LICENSED CONTRACTOR'S DECLARATION �®
I Wreby affirm that I am Iicemctl under provisions or Chapter Y(commencing lob Description ��
�Z, with Section 7")of Division 3 of the Businus and Profusimu Code.and my litems,is //(�
<<�� in roti maeand ef, req, z ,2 a. REROOF a/U
2 z License Clan-r-� .''i`—lis.. 10 p4
Fp Dem C-nox"O
DELL
ARCHITECTS DECLARATI ds pq�y yp s.
I understand my plans shell W used u public rtwNa �9�®"•®�agY�
QWti Licensed Pmfessiaml VV
OWNER-BUILDER DECLARATION
i F I hereby aIB.Nu 1 em exempt form the Contractor's License Law for IM
-.00 following motion,(Section 703 1.5,Businea and Pmfmoum Code:Any city or county
x$ which mquiro a permit to conaap
conaria.alar,improve,demolish,or mpeir say storcmrt
onn
v— Poor mita issumm,also requires theappliant fa..uch permit Or Ile asigned statement
that W is licensed pursuant to the pmviaiom of the Commctors Limns,Law(Chapter 9 Sq.Ft.Floor Area Valuation
9 $ (commencing with Section 7")of Division 3 of the Business and Pnf.ssi...Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty or 3 4dXN3 Ijft3Ber0 0 Occupancy pry•
not mom than five hundred dollen($500). P y `7I� ,
Cl I,a owner of the property,or my employ=wish wage as their sole eumpensadon,
will de be,work,and the structure is not intended or offered for sale(Sec.1045,Businev
and Pmfeeslom Code:The Convectors License law d=not apply to an owner of Required Inspections
property who builds or improm thereon,and who does such wink himself or through his
own employ=,provided that such Improvements as,notinmnded oroffered for sale.If,
however.the building or improvement is sold within one year of completion,Ne owner. .
builder will have Ne burden of proving that he did Out Wild or Improve for purpose of
sam).
❑h as owner of the property,am exclusively contracting with licemed contractors to
comtmct the pmjm(Sec.7W,Business and Prof easimu Code:)The Contractor's I.I. .
cane law docs not apply man owner of property who Wlids or improves thereon,and
who concocts for such projects with a cantractorm)licensed pursuant to the Comommes
Limuse Law. -
❑lam exempt under Sm. .B k P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following declandom:
I hoe end will maintain aCeNfinm ofComenuoalf-Insure for Wortci aComp.n.
abort,as provided for
by Section 3100 of the LOW,Cade,for she perforin;...of she
work for which Nis permit is issued.
NI hew:and will maintain Worker's Compensation Insurance,a required by Section
7 of the labor Cade.for the performance ofthe work for which this perms is limited.
My Workces C1ompenfadon his...mcas .,and Polirynumberem: _
Carrier. C"1 Gk lT —I�-lx st d Policy pat, t 4-A T 15 G
CERTIFIG Ol�P ION FROM WORKERS'
COMPENSATION INSURANCE
QT6 sec0an need not W minpletod if the permit H faronc Wndmd duilars(3100)
or lea.)
1 certify that in she performance of dm work for which this permit is issued,I shall not
employ any person in any manner»as an become subject to she Worker'Compensation
laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ce tureare of Exemption,you should
become subject w the Worker a Compcnsetien provisions of the Labor Code,you mint
O forthwith comply with such pmvi9ons or this permit shall W deemed revoked.
ti CONSTRUCTION LENDING AGENCY
(-s Thereby affirm that sham Is a construction lending agency for the performance of
a 7 the work for which But,pannit la Issued(Sec.3091,Civ.C.)
CA lenders Nam.
7 z Lenders Address
U Q I certify that 1 have rand this application and sum that the shout InformNun is '
F commit,l agree to comply with all city and county urthnsnces and sum laws mlating m
0 Wilding construction,and hereby authooa repmsematim of Nis city to enter upon On
4T7 shove-mentioned properly far Wpecuon purposes
(We)agree to ave,indemnity and keep harmlea the City of Cupertino against
h Ilablllua.Judgments,casts and expemn,which may In any way accmc against said City /'
at
U 2 in consequcrme of the graining of this permit. 1/
ti APPLICANT DER TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG NS.
V1� ' 1 /G`( Re-roofs
Signature of ApplicaaUConmmwrDam
HAZARDOUS MATER ALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant Blore or handle haardous material
as dented by tW Cupertino�+a�Iciapal Cade.Ch ipmr 9.12,and the Health and Safety
sale.section 25532(.)7 X All roofs shall be inspected prior to any roofing material being installed.
[:]Yin tT
Will the applicant or future building occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hiamnm air contaminanss as armed by the Bay Ama Air Quality Management all new materials for inspection.
District?
0yes Nu
I have mad the haardoustimuoulsmquiremenu under Chapterb.95 clubs Califon _
nice Health B Safin Code.SecWm25505.25533 and 25534.Imidersund than if dm Wildin yrs ^y
J=not curet y a amanl thn i,is my reapomibility to notify the eccupsnt ordm �r✓� 'I I s � 'O``
rem, mnuw,c asWmet Poor toissuanceoraCertiramor o1c.paricy. Signature of Applicant Date
I , oy
owner ar aamarixea,gem DateAll roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
15;UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
.1 a s 5 3 Ml ooc-�r-%cS e. (t� 0`( 0 7 0o
OWNER'S NAME: H c\�r� N ct e v PHONE # A54 - o:11S;14
GENERAL CONTRACTOR: a D Roo Z FAX #
I am not using any subcontractors: o N
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
All Tile
� 15 0
Owner/Contracto ignature Date
Community Development Department
Building Division
City of Cupertino
i
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 shafted policy on re-roofing.
Homeowner's Name: a Ci rj a
Job Site Address: & a S S 3 A % n o
Roofing Company Name: D �k
A plicant's Signature: Date: i S l o U
eal
Greg t
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO o ,7
REROOF
,.� OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
34a tS O6 3 I IS ( oma(
Building Address:
a S _e e
Owner's Name: Phone#:
Nervi N0. c{,e.l _S O Sy
Contractor: Phone#: License#:
I D Ro03 cg q q Ioy �_ G 6 6 2 a-
Cont ct: Phone#: Cupertino Business License#:
es e Noaw `b°I a- S-3-V,-
Type
SType of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
X Wood Shakes Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
XTo be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: NW
` Job Description:
hemoVe v�loocl S �to u ACA w; K Sb �reAi�av�"�c
Residential & Commercial ❑ AG U S
Fire Zone: Yes ❑ No Confirmed with miigpept. if
there are anstrictions:
Cost of Project:: c Type of Cons tion: Occupancy grow :
IO CLM ,IC�Ol7 f
Qty i
A a ej 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
a
2, 6 3 c: .
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