04080147 .CITY OF CUPERTINO �� 'F'y 'may '( �a,'"F y.�
BUILDING DIVISION PERMIT4_4® Q �'Y�'�' L`f;p^'±
BUILDING ADDRESS: PERMITN0.04080147
Q71 1 WITISTI)RRI-Trw DR OWNER'S NAME: PERMIT L5SLIE DATE
FRANC SANITARY N 0 OL N0.
NE:
ARCH1TECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0
Y00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 kmby affirm Nat 1 am Itemacd under provisions of Chapter 9(commencing p
with Sec0on 70(11)of Division Sof thc Business and Podlessium Code,and my license is
� „ in mummeand Re �/� REROOF W SHINGLES-
B Z D�aunse ClAS Conmacyg /
ARCHITECTS DECLARATION CONTRACTOR: MENDOZA ROOFING SEP ��` POO4
$ 1 understand my plana shall he used As public mcenda
BUILDING
i O Licensed Professional
3 OWNER-BUILDER DECe CmureON
a 1 W m o.(Rrm on 1 am exempt from We fess mcmfs License Law for the
y p O following moon.(Sadao 7(131.5, t,Business and Prerte,de an Code:Any ally or ieounry
oe$ whichitsistrequires a permit In construct,ploy improve,demolish, file
repair any swcmm
yew poor to iuuencc.also rego the the applicant ontrch crmr's Lim asLaw(ned uroment 9
E££x�xa that he is licensed pursuanunthe provisions n[the Canmcmr's License Lew(Chapmrc9 Sq.Ft.Floor Area Valu
yF$ (commencing with Section 7000)of Division 3 of the Businemml Professions Cede)or
Nat he Is exempt tharsfrom and the basis for the alleged exempdon.Any violation of
Section 7031.5 by airy applicant for a pewit Subjects the Applicant 0 a civil penalty of AISN Number Occupancy Type
not mart thm five hundred dollars(5500).
❑I.nowmrofthepmpmyormycmploWowiibwagnutheirsolecompenudon, 37529021 . 00
Will do thewodr,and the twcmm a notinunded oro@sed for..le(Sm.70d4,11wime a
and Profemions Code:The Connector's License Law does not apply m an owner of Required Inspections
property who builds orimprosea Narcan,and who doessuch workhlm,elfar through hit
own employees,provided thatsuch improvements are not intended arolfered for tile.If.
however,the building or improvement is Sold within ane year of complcdan,the owner.
builder will have the burden of proving that he did Out Wild or improve for purpose of
❑I.as owner of the pmperty,am exclusively contracting with licensed Lonuacmrs to
construct the project(Sec.7014.Business and Profusions Code:)The Commences U.
cense Law does not apply to an owner of property who Wilds or improves therean,and
who contracts for such Projects with aconwcmr(s)licensed pursuant to use Contractors
LKmY LAW.
0 1 un exempt under Sec. B A P C for this season
Owner Date
WORKER'S COMPENSATION DECLARATION
firm
1 hereby afunder penalty of perjury am of the following declarations:
1 have and will maintain a Comftcate of Canter,.self-intim for WorkersComper-
A iu
tion, provided!for by Section 37011 of the Labor Code,for the performance of the
work for which this pewit is issued.
0 I have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the Labor Code,for the pertomance of the work for Which this permit is luued.
My Work�e.r,sy�7n]m'7R/py/satron In¢unnce eamier and PoHey number a2:
Cartier.✓1rL(-^ • ♦ t-J IICY No.;�Q�
CERTIFICATEOFE M ON PROMWO KERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit isfaronehundmd dollen($100)
or less)
I certify that in the performance of the work for which this permit is immd.I shell nm
employ any person in any manner An AS N bceomosubject to the Worknot Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption.you should
become subject to the Worker's Compensation provision of Ne Leber Code,you must
.,O forthwith comply with such previsions or this permit shall he domed mwked,
Z y CONSTRUCTION LENDING AGENCY
[--i I Wmby Sir.this Nem is..mtAI tftm lemling agency for Ne performance of
Ca > the work for which this Permit Is issued(Sce.3097,Civ.C.) _
oa Qen
Lder's Name
z Lender's Address
U O 1 certify that 1 hive mad this application and aura that the above Information is
cowct,I agree to comply with all city and county ordinances and auN laws relating N
V building convection,and hereby authorize rcpresenutom of this city to enter upon the
W above-mentioned property for inspection purposes. /
L (We)agree to taw,indemnify and keep harmless the City of Cupertino against
„y N lo"ditim,jud cnts,cots and expenses which may in any way ocean agalnt mid City
V,`�� in co a of Nc Bmming of this permit.
APP 1 A UNDERSTANDS AND WILCOMPLY WITH ALL ON-PINT Issued by: Date
SO GULATIONS. r
O Re-roofs
na mofA IicmVContrecros au
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle huardous material
AS fined by the Cupertino Municipal Code.Chapur 9.12,and the Health and Safety
Code,Scction25532(.)7 e't+/ All roofs shall be inspected prior to any roofing material being installed.
0 Ycs
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
mit heaomus At,em uminmts asmcd by the Bay Area Air Quality Management all new materials for inspection.
Dorm,?
OYcA No
I have mad the hmardousmamsiala mgti.mcnu under Chmtn,6.95.f dba Califo> �.
nu He. S(ctyca ,Safi m75505,25533md25534.lundet dihatifNc Wilding
Jars Le tly ham a anent that it i.my r�ponibibly m notify the nccupant of the
.1 re wNchpaustbcmxpoonuiuu cofaCc 'RcauofOc a racy. ig tui/of 9pplica,lit D
nas antl is agent am All roof coverings to be Class "B" o better
Community Development
10300 Torre Avenue
t' Cupertino CA 95014
Telephone(408)777-3228
M'CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDREZ! PERMIT
107// i e
OWNER'S N ci :Teldl F #
GENERAL CONTRACTOR: 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
0
y /Contractor Signa \ I ate
Community Development Department
Building Division
s r ' City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
OCITY 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 abovestatedpolicy on re-roofing.
Homeowner's Nam
Job Site Address/ 27// WLIV rdUg /(.
Roofing Company Nuatf: Z.A — Al& .
A plicant's Signae - Z�
• Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
00 REROOF 6� a 9 61/q 7
CUPEkTINO PERMIT APPLICATION FORM /
APN# 12/1 i Date:
Building Alles
Owner's Name Phone#:
Atiu i L
Contract r: Phone#15-Jp z,/3c03�Pq- License#:
Co c Phone#: Cupertino Business License#:
ao
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes 13Wood Shakes
C3Wood Shingles 13Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have R ad, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Desc o y ^ 2
Residential scy Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Panning De t.
there are any restrictions-
Cos Prot: Type of Consteu do Occupancy group:
Qty. if
AppjkRe 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
2v