05070163 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ',2 T CTnR INFORMATIO.N"i"`,:.
ear_,-.�C�'V.r ..�_G!A_
BUILDING ADDRESS: LINDY ROOFING CO INC PERMITNo.05070163
6C;21 ("T.T17FORT) DR
0 R'S NAME: PERMIT ISSUE DATE
TOM HU
PHONE: SANITARY NO. CONTROL NO,
(408) 286-9990
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ups LICENSED CONTRACTOR'S DECLARATION oni
i
Job Description
w 1 hereby affirm that 1 em licensed under provisions of Chapter 9(commencing
i`uf with Scniun)OOU)of Division Sof the Bassin ua ciPmfessions Codc,andmylicenseis i'j'49 qini
_<= Lrc^iheeanaerce� 3 ue.a �1'Sv�4p REROOF-REMOVE SHAKE .ROOF%,INSTALL
;k,w Date Commmr (vo _ SQ NEW COMPOSITION ROOF ° �� •y-ti+'ks®
,� ARCHITECTS DECLARATION
>�VI �mmtlxa1andmyplansshall tc..it..public record, _ 220(t0�15q
cod Licensed m iunal � _ 2`Ya!
5 OWNER-BUILDER DECLARATION
ai
I berchy affirm Nat I am axcmpt form the Coanclors Liecnse law for the tn�r�$ �I Q@
00 following reason.(Section 7031.5.Business and Professions Code:Any city or county fr^R {j (j }� ���,�
i 2� which requires a permit hr etinsrun,aluf,improve,demolish,or repair any strucmm �fffii##oo�yyy (I(L y b' (t c+a
prior It)its issuicc.also requires;the applicant for such permit to file a signed statement -- teas
<
that in is licensed pursuammthe pmvisionrofOcContractor's Lommem1aw(Chaptcr9 Sq. Ft. Floor Area
Vahiati$�000
EEC (commencing with Section 7")of Division J of the Business and Professions Codc)or
y Nat M is exempt therefrom and the basis for one alleged exemption.Any violation of
Section 0071.5 by any applicant for permit subjects the applicant to a civil penalty Of APN Number Occupancy Type
no,mote than fiva hundred debars($500). 36926002 . 0 0
❑1,as owner of the property,or my employers with waged as their sole compensation,
will do the work and On,avucmm is not intended or offered forage(Sec.7141,Busineu
and Professions Code:The Contractors Lieenu law does not apply u an owner of Required Inspections
progeny who builds or imprhws Bottom,and who does such work himself or through his
own employees,provided that such improvements arc not intended oro@red for sale.If,
however,Ns building or improvement is sold within one year of completion.On owner.
builder will have 0¢burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑1,as owner of Ne properf,am exclusively convening with licensed contractors to
consumer he Pmjen(Sec.7014.Business and Professions Code:)The Commmor's Li"
cnere Law docs not apply to an owner of property who Wilds or improves thereon.and
who contracts for such projects with a commelor(s)licensed pursuant to the Character's -
License law.
❑I am cramp,under St. .B&PC for Nis reason
Date _
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under penalty of perjury one of Ne following declarations:
❑I haw and will maintain a Certificate of Consent to self-insum for WmkersCompen-
cation,as provided for by Section 3700 of Ne Labor Code,for Ne performance of the
.,it for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance,as requimel by Section _
3700 of rM labor Cods.for the performance of the work for which this permit is issued.
My Work.:.Campensetih xurance carrlm and Polity numbe,am:
Came I f-f%at4 j Policy No.: I SS 160010
CERTIF ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuctiurecd nmboChmplC¢diftkpermitisfinenchMn dollars($10())
or lac.)
1 cemfv Nm in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner so in to become subject o the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifiau of Exemption,you should
W Ome subject to the workers Compensation provisions of the labor Code,you must
.J O forthwith comply with such provisions of Nis permit shall W deemed revoked.
Z17 CONSTRUCTION LENDING AGENCY
[+ IMreby affirm Nat there is.construction landing.gency for the lcrfnmance of
aNe work for which Nmi
Nu pert is Word(Sec.7097,Civ.C.)
W0 tondo's Name
W
0. z L.ender's Address
U C 1 certify that 1 have read this application and sum that the above information is
W^� correct.l agree to comply with all city and county on imams and Sum laws relating in
U building construction.and hereby suthorim repreunmirs of this city to enter upon the _
W ahovcmentioned property for inspecdhn pu0wus.
gy (We)agree to skive,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way acetic against said City
U Z in consternation of the granting of Nmit
is per .
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 22 6-r- b
ToHaCE REGULATIONS.
1121¢ [� Re-roofsC,
Signatu ApplicanUContraclor - Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicam or future Wilding occupant amm err handle hes Mous material
as defined by the Cupertixrutm
Code.Chapter 9.12,and Oc HcAth and Safety,
.Seenen 255J2(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicam (ding occupamvu cyuipmcm or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit harammen air contaminants dcfincJ M1y the Bay Area Ai,Quality Management all new materials for inspection.
Disrin0
Ej yes
Dyes
lhave real the havaNnus materialsmyuimmcnts under Chapmr6.95 hf the Califor- `
nu HcalN&Safety Code.Scedons 25505.25377 anJ 2553d.lumlersund this if the Wilding
rat eunendy haw a.e L that it u my tuponsibility to ratify the occupant of th mit
goim Bwhi mug bcmet poor tuissu� anceo�ti�camofOccupanry. Sig re of Applicant Date
own rr qt nttdscnt Dam All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
�JPEt�TINO Fax(408)777-3333
Building Department
JOB (p5 Cr 1 � � PERMIT#
1 ra.� ( 0so-7o � G 3
OWNER'S NAME: 'pry 1 PHONE #
GENERAL CONTRACTOR: Ll,v 4�:j Co FAX#
I am not using any subcontractors: Z k.�
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
41 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
It2m 3 of 3 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 36926002.00
DATE ISSUED. . . . . . . : 07/26/2005
RECEIPT 4. . . . . . . . . : 30514
REFERENCE ID # . . . : 05070163
SITE ADDRESS . . . . . : 6523 CLIFFORD DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : TOM HUI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4555
RECEIVED FROM . . . . : LINDY ROOFING
CONTRACTOR . . . . . . . : RUMFORD, LINDY LIC # 3921
COMPANY . . . . . . . . . . : LINDY ROOFING CO INC
ADDRESS . . . . . . . . . . : 5554 HARVARD DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95118
TELEPHONE . . . . . . . . : (408) 286-9990
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 10, 000.00 169.56 0.00 169.56 0.00
BSEISMICRE VALUATION 10, 000.00 1.00 0.00 1.00 0.00
_____ ----------
TOTAL PERMIT 170.56 0.00 170.56 0.00
METHOD OF PAYMENT AMOUNT NUMBER
CHECK 511.68 1104
TOTAL RECEIPT 511.68
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
• C[ OF Telephone: (408) 777-3228
CITY C U P C'`T 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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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: II _ViMIJ [fjU I ,Q
Job Site Address: fa��0
Roofing Company Name: Ll "'2'4 PILOPW-rz
Applicant's Signature: Date: jZ�
® Greg Casteel
Building Official .
Revised 11/2/04
Printed an Recycled Paper
awt
CITY OF CUPERTINO
REROOFCUTINO PERMIT APPLICATION FORM ��� ��1��
APN# � /p/ Date:
Building Address: S�3 GI t n( _J Y t�/-aO
Owner's Name: , 11 Phone#: np
Contractor: _ License#:
Ccs ;)-1581 rP
Contact: Cupertino Business L'cen e
�l e ft 3
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
>ZL Asphalt Shingles K Asphalt Shingles
❑ 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 Mfg.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tepr Off Policy:
Job Description: l'"er^vv°-- on jf oti Qn rn,S r�5
re (5-- n.t,w s, ,n ru.)P Ce ,n
Residential Commercial .❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of ProJ T e of Construje � non: Occupancy group:r)�( e r007 Sln
Qty. if
Applicable 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
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