04080061 (2) CITY OF CUPEWTINO k'""' " '^"
BUILDING DIVISION PERMIT C®NTRACTOR INFORMATION ;
nuII.DINC ADDRESS: PERMIT N0
INTEGRITY ROOFING 04080061
OW NER't NAMEj2p R9
: PERMIT LS9UE DATE
ONE:
SANITARY Qg*OL N0.
ARCHITECT/ENGINEER: BUILDING PERMR INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S DECLARATION JobDescri [tori
s F 1 hereby affirm that 1 am licensed under provisions Of Chapter 9(commencing p
sir`$ with Section 700l Division Softhe Business anil Professions Code.and my licensor is
n« in fullfc�yurid effect. �� F n '�"
5'q_ Lieenar x 7 Lie' REMu.VEF&��RmEI�SLQRCE��/$.HAKE TO COMP SHINGLES
nt-� DatcARCHITECTSD tCa�r RA7jON 9 `L9Y '�a`�aaE Ilvoq
dCrsuOd my plans shall he used as It erds
3a� Licensed Professional JAN 3S 2005
`01
OWNER-BUILDER DECLARATION
<� 1 hereby Affirm that 1 am exempt from Rhe Contractors License Law for the ram
a o following mason.(Section 7101.5,Business and Professions Calc:Any city Of county Il�epe n A
X m� which requires a Permit m Bosman,alter,impruw,dcmolLsh,or repair any rme ure Is N n N
,! fn prior it)its issuance,also requires the applicant for such Permit file a signed sutement
Vie that he is licensed pursuant to the provisions of the Comment's Liecns Law(Chapter 9 Sra�Ft?Fldbr Aieap� VaIU LI00
�Ire-0 (commeneingwint Secum)W0)of DjvfOon3nfihh Busincssand Professions COIC)or
he Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.3 by arty applicant for a permit subject the applicant to a civil penalty of 3Wtlli�gr00 Occupancy Type
not mom than five hundred dollars(SS0% r
I,as owner of the property,or my employees with wages as chair sole compensation,
will do the work.and Ne structure is not intended or of xod!fo..alc(Sec.70I<,eosinest
and Professions Code:The Conuacmrs License law dos not apply to an Owner of Required Inspections
Impiety who builds nr improves thereon,and who dassuch work himself or through his
Own employees,provided that such improvements are not intended oroRered for sale.if,
however.the building or improvement is sold within one year of completion,the owner
builder will ban the burden of proving that he did not build or improve for purpose of
sale.).
❑1,az owner of the property,am exclusively contracting with licensed emnmctors to
construct Ne project(Sea.rasa,Business and Pmfassimma Cade:)The Contractors U
ce ue Law does not apply to an owner of progeny who builds or improves Recon.and.
who contracts for such projects with a Bort ractor(s)licensed pumuam m that Convacmr's
License Law,
❑I am exempt under Sea .B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declariondes:
1 ban and will maintain a Certificate of Consent in self-imsum fm Workei sCompen-
cation,as provided far by Section 37M of the labor Code,for the performance of the
work fuse which Nis permit is issued.
1 haw and will maintain Worker's Compensation Insurance,m required by Section
3,Waf Nel-amr Cate fmrthe performance fthewortforwhichma Kin titisissued.
My Workers Compensation Insunn<c cam and Policy number are
rice, 3717— - Policy No.:(=//7
CERTI ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSL%A
(This section need not be completed if the Permit is formic hundred dollars($100)
or Icasj
I eerdfy for,in the perfnnri of the work for which this permit is issued.1 shall nut
employ any person in any manner so az to hceome subject o the WaYeri Compesauom
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificate of Eaamption,you should
become subject to the Worker's Compensation provisions of the Labor Calc,YOU must
.J O forthwith comply with such provisions or this permit shall he deemed evoked.
Z^ CONSTRUCTION LENDING AGENCY
[—rte Ithreby affirm Nat Neseis a eomRructinn lending agency for the perfurman¢uf
C Ne work fur which this permit is issued(Sec.3W7.Civ.C.)
W Q undcrs Name
]Z lancer's Address
J Q 1 chief,that 1 have mad this application and sate that the show information is
ty P correct.l agree to comply with all city and county ordinances and state laws relating to
pU building construction.and hereby authorise representatives of this city to enter upon the
W show-mentioned property for inspection purposes.
(~ t1 (We).,me to save,indemnify and keep harmless Roc City of Cupertino i gaiso
N liabilitie,judgments,costs and expenses which may in any way acerae against said City
U in rosequenec of the Standing Of this Permit.
^ APPLICANT U DERSTANDS AND WILL COMPL IThl ALL NON-POINT Issued by: Date
SOURCE RE ATIONS
Re-roofs
tea App! nV dor Dam
HAZARDOUS MATERIALS DltCLOSUIf Type of Roof
sthe applicant err fuses building uccupam smrc or handle hamNuus material
3aidtffiined by Use Cupertino Municipal Cafe.Chapter 9.12.and the Health and Safely
Code.Seco..25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Wm the appu'an r future building meop of use cyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit M1anrdnus air coma 6 defined by the Bay Area Air Quality Management all new materials for inspection.
'is
a?
❑Yes ]Nu
Ihave&SaC theluaaNnuss M50alsmquand cras M34.I understand Cha6.95
dust
the Wilding
n;a Flacth&Safety Code,therms255(15, my ocend2353a.1 UsnodIthat CUPO Willing
Jas act currently haw a tenant that it is my mspmvibility m nmol,tM<upant of the
routine hrec. at prior to wurungAf a ceniGeate of Occu ey. I'
SiAnaturApplicant ate
r or ammo,. agent Date All roof coverings to be Class"B"or better
f
_ Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPERTINO
Building De a tment
JOB ADDRE PE # �q D C9 0
OWNER'S N 5 U n PHO —
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
® � g�
Contractor Signature ate
Community Development Department
Building Division
s'.i� City of Cupertino
aY. „ " 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E IST I N O 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 c mply with the above stated policy on re-roofing.
Homeowner's Name:td 57ryc h
Job Site Address: 751 ,A11A '@nr-AT�
Roofing Company Name: N
A plicant's/Signature: \ Date:
\ilJr61N(X�
l
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO D MDQ I
REROOF
CUPEkTINO PERMIT APPLIC�,TION FORM
APN# U Date:
Building Address:
12_ 2
Owner's Name: Phone
STiGuF i( k.
Contractor: Phone#: License#:
Contact: Phone #: Cupertino Business License#:
5y5- 8'732
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles �K Asphalt Shingles
—3Y Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
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 Description:
`2 ewv Ityjc t I5AIA KE
Residential Commercial ❑
Fire Zone'/YES❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: LJ
Co of Project: Ty�e, of Construction: Occupancy group:
1Z as ICzrr�F
Qty.
A c ble 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