04010038 (2) crry OF CUPEwrwo p y`
nulLofrdc DlvlsroNPERMIT jfCONTRAC, R INFORMATION: h
.BUILDING ADDRESS: CEDAR ROOFING PERMITNOO4OI003B
OWNER'S NAME: PERMIT MUEDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
O o LICENSED CONTRACT'OR'S DECLARATION
[[u, a hereby W of that 1.m Restated E under Isms as of Chapter 9(commencing Job Description
<i to
withm5enim ande)ec Division 3of the Business orad Pro&ssinns Codc.and My license is FI� q LE0
nI2„ LimumreaandmrraL REROOF Lal"`1k 9�
i u License Clan Lin.a
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yy
ARCHITECTS
TS DE DECLL
ARATION JAN
N 2 2 200
IundcratanJ my plana shall beused a/h1(Y 4
J es public records Y
o Liecosed PnRcssisnal
tr,3 OWNER-BUILDER DECLARATION BUILDING
R C) I hereby affirm the I am exempt from Use festoons,Co License Law for the e
0 o whicfolloh re massa Permian](111.5,Business and improve,
Professions,demolish.oc:Any city or county
K m which its iss x n)omit re cnnssuck alar,improve,hPermittfi repair any ument
°_t thructure
at Itoor incensed purse rtyvitcift he poomonsofant to for sucContractor's
Eense Law(Chapter
x�$< (commesEmoudpSrsuaottothepfDivinonoftheBlracmraumcnYvwtchaptrry Sq. Ft. Floor Area Valuation
(cnmmcncing with Scnion]I1fNl)of Division)of the Busincssand Professions CtWc7 car
y _ that he is exempt mcmfrom and the basis for the alleged exemption.Any violation of
Section?031.5 by airy applicant for a persichadjeca the applicant to a civil penalty of 32'81N$'I1�l Cr00 Occupancy
not more man five hundred dollars($500). P Y Type
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(See.7044,Business
Md Pmfcssmns Code:The contractors License law does act apply to in owner or Required Inspections
progeny who builds or impmwa thereon,and who does such work himself or through his
own employees,provided that such improvements Be not imended oroRemd for sale.it,
hawevcr.the building or Improvement is sold within one year of completion.the owner
builder will have the burden of proving that M did not Wild or improve for purpose of
is sale.).
0 1,as owner of Use property,am exclusively contracting with licensed Contraction to
ematmet the Project(Sec.7060.Business and professions Codc:)The Contractors Li.
attic law docs not apply to an owner of property who Wilds or improves thcmon,and
who contracts for such projects with a conlranoris)licensed pursuant to the Contraction's
License law.
❑lam cacmps undo B&PCf this ave
Owner COMPENSATION
Date 124 0
WORKER'S OMPE SATION DECLARA710
1 Wreby an rte under petalty of perjury arc Of the following declasairms:
1 have and will maintain a Certificate of Consentto self-insum for Worker'sCom)en-
ration,a provided for by Section J]W of me Labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as;required by Section
37M Of the labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insuntuc carrier and Policy number aa:
Carrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
O'bu uetimt need not bemomplacd if the permit is,moo,hundred dollars(SIM)
fast.)
1 certify that in the performance of the work for which this permit is issued.I shall nut
employ any yermn in any manner so a to become subject to the Workers Costpematimn
Laws of Calif enda.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Workers Compensation provisions of the labor Come,you most
.Jz forthwith Comply with such Provision or this pi shall W deemed revoked,
CONSTRUCTION LENDING AGENCY
F
T bereh (firm Nat drum is a Cn LUMCUM lending g agcnq Lot ft lwrfutmatuc of
5 the ,it for which Nu permit is issued(ere.3097,Civ,C.)
W Q lender's Name
D' Lender's Address
oz
V Q 1 certify that 1 have read this city
ad coup and sem the and
salve iws mladun is
coocIy F
building
uilds t.l agree to comply withallauthors representatives
nNtives of and sum laws rupon the
t.7 abovengcotioned construction,and hereby amhonprposesematives of this City mcnmrupon the
ahovcmemionmdprogeny for inspection which s.
F y (We)agree to save,indemnify and keep harmless the City of Cupertino against
C/1 inconsequenc men¢Costs and expenses which may in any way accrue against said City
U z A APPLICANT
or UNDERSTANDS
granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 6�
Date
SOURC R 9Li 0 . /l1
2
Re-roofs
Sign ore of ApplicanUContmcmr
HA2ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant to
(tome Wilding twcupmt Blom or handle harardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Codc,Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑rtes ❑Nu p p � Y g g installed.
W"'me appbcantOr Comm building occupant use equipment at devices which If a roof is installed without first obtaining an inspection, I agree to remove
$11 harardous art coomminants as defined by the Bay Area Aa Quality Management all new materials for inspection.
wrier?
0Yes ON.
Ihave n&SaRt theha]atcuons2 500 requirementsMd255 under Chapter695 of the Calirnr, / I/ D
nix Hcabh&safety Curie,Senium 255(15, MYFeSnJmmilfll undersande OCCOMWilling \ Ay' - el n'/^ ��
rima not currently IoM a tenant,heat it u my tnponaihility m nntifY the acupant of dm O�YI' /!tic-�e_
mquiremse bichmuBxme, toinuacmOf.cetdrmBmof7pency. S' aureofApplicant Date
V /—11 All roof coverings to be Class"B" or better
caner or amhodacd agent Dam g
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
I No Fax: (408)777-3333
UPEkJ
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 Na*le? //� d�//
Job Site Address: l 7S7 �� LY _57
Roofing Company Name: �C�_-�-e Dix/z
A plicanYsSignature: - iu _ Date:
\A/�il/�1DLJV.
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Y
CITY OF CUPERTINO
w an REROOF °
CUPERTINO PERMIT APPLICATION FORM
APN # n / n D Date:
Bu'1 iggAd/d}re
U
Owner's Name: P one #:
S' CZj 3 67
Contractor: jfl icense
Contact: Irflone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt ShinglesAsphalt 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 Mfgr. Installation$ ecs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
Residential Commercial 1 17
Fire Zone: Yes ❑ No ❑ ` Confirmed %vth Pan e
there are an. -
Cost ct aro Type of Cons o Occupancy ro
Qt . if
A li abIll 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
4W- 7. 7