03070195 (2) ( CITY OF CUPEWI'INO - =>=� >v- AcA
BUILDING DIVISION PERMIT CONTRACTORINI'ORMATION
Bu11n1NcADDRESS' COSMOSNROOFING PERMIT No 03070195
OW NL'R'SNAME: 1901 OLD MIDDLEFIELD WY PERMIT ISSUE DATE
ONE: (415) 493-6373 SANITARY NO. CONTROL NO.
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+op LICENSED CONTRACTOR'S DECLARATION O O O O
£w 1 he¢hy affirm that I am limnsed under previsions of Chapter 9(commencing Job Description
W with Section 7000)orDivision 3 train,Business and Professions Code,and my license is
ius cfeunll aerm�el.�an-�dt-f3� c
^L oJ
REROOFel
DCTp Cum 46.
1 understand myplaARCHITE nsshall rc
AUG 2 12003
a J
too G Licensed Professional
3 OWNER BUILDER m Ce Contractor's
ON
C n O 1 acres. ,(firm that 11. exempt from the Contractors e:Any
Law for the BUILDING
O o following uiassn.(Section 7onstr Business and improve,
de oft Code:Any city or county BUILDING
e m which its requires a pctmit re requires
et,aafter,pplicant
impmsu h Permit
erm ti or repair any structure
°It $1 c1pro
that to hoitscenced e.pnwmquims lhovisio csof far Contrator'tofile aicense ned aw(Chmmcm
:zp thalhcincing ithSection7gent tM1)ofDisimoo or theStrsiness ndProflaw(Code)or Sq. Ft. Floor Area Valuation
r t- (cothat k is Ciampi erclo in and t f Dings f rth the Business and exemption.
vi Code)or _
i
that io is excmpl any applicant
li and the boo for the ct the applicant
On Any violation of 32644028 . 00
Satan 703 Lshy hunapprnnt rorapetrnH anbjcets the.pplfeantto.aml penalty of APN Number Occu ane T e
not more than f hundred dollars(SNp). p y yp
❑L a owner of the property,or my employees with wages as their sole compensation,
will do the work,and toe structue is not intended at offered for sale(Sec.31244,Business
and Prefessiom Code:The Convumr's Liccae Law docs not apply to an owner of Re uired Inspections
property who bunds or improves thereon.and whoduessuchwork himselfor through his 307 - INSULATION
own employees.provided that such improvements are not intended oroncrcd for sale.If. 6O1 - ROOF TEAR OFF
however.Ne building or improvement is sold within one year of completion,he nwncr-
bidder will have the burden of proving that be did Bol Wild or improve fur purpose of 602 - ROOF PLYWOOD NAIL
ealn.).
❑1,as owner of the property,am exclusively contracting with licensed mnoaetars to 603 - ROOF BATTENS
construct the project(!ec.7Ud4,Business and Professions Code:)The Contractor's Li. 604 - ROOF IN-PROGRESS
Curiae law docs notapply to in owner or property who Wilds or improves thereon.and
who contracts for such projects with a eontracou(s)licensed pursuant o the Conuactor a
License,Law.
❑ I am exempt under See. ,B&PC for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby alarm under penally of perjury arm of the fallowing deelaranind: -
I have and will maintain a Cer ifcam of Consent 1.self-inure for Worker's Compere
sation,as provided for by Section 37M of the Labor Caere.for the FCKOMO ec of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,a requited by Section
of the labor Code,for the performance of the work for which this pemot is issued.
My Wmkcr C nation t suranc carrier end Policc�yrrnurnkr mc:
Cam Policy Nom -0Z—I I Z..S
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed it the permit is for one hundred dollars(SIM)
or luxe)
1 cenify that in are perrmmance of the work for which this permit is touted,1 shall not
employ any person in any manner so a to became subject o the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should
become subject 10 the Worker's Compensation provisions of the Labor Core.you must
�`t, languid,comply with such provisions or this Permit shall W deemed emitted.
Z'O CONSTRUCTION LENDING AGENCY
1 hereby affirm ton there is a construction lending agency lot the performance of
x the work fm which this permit is issued(Sec.3097,Ci,C.)
1 lender's Name
7 Z lender's Address
..)0 1 minty that I have read this application and some that the above information is
y f-' Comet.1 agree to comply with all city and county ordinances and suit laws relating to
JU building Conswction.and hereby authorise repracntatives of this city to COW upon the
}[Sl shavomcntioncd poreny(a,iapcaion purposes.
r C (We)agree to uve,indemnify end keep harmless the City of Cupsmour against
h Iiabilitia,judgments,costs and expenses which may in any way ac'cmc againsteald City
JZ incaraequenccofthe mntingafrh"N ``t
.. SOURCE APPLICANE U TI STAND ILL CO �.Y WIJH ALL�/NON OINT Issued by: 6" Da e
Signature of Applrwn �, ! az/6 Re-roofs
Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will are applicant in future building Occupant shore or handle hasechus maetlal
az dcfincd by the Caperton Municipal Code.Chaper 9.12,and the Health and Safety
Code.Seaton 25532(a)?Ycs All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havaNsus air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
istria7 _
[3 Yes ,'�'•�/
I,,remad lhehmSeenus macrialsrtqui anunuunJcrCcoused t9softhe Califon e���K�4 a
iia Healto&Svfery Cwle,Secdua 252413.2x53]and 25534.1 understand lhazif the Wilding
does not currently have a®sant,tom it 1 my respansihility m nndly the Iaxmpant of the 1,510
mquirtmenkaw slW tp' Issuance CeniGpa¢of
Signature of Applicant Date
owner anmad.e�s 7��s/v3 All roof coverings to be Class "B"or better
Community Development Department
Budding Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPS TING
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.
Xc- C st
Homeowner's Name: iu_
Job Site Address: IOSS 2— /C/a-�
Roofing Company Name:
A pI'cant's Signature: Date: x,5103
eel
Greg t
Building Official
Revised 1/30/03
Printed on Recycled Paper
07/25/2003 12: 45 5105383202 LEGALITIES IN✓. PAGE 03
CITY OF CUPERTINO 3
t- �►.... REROOF
aa C> J �/
�UP,ERJINO ✓ P�IZMIT APPLICATION FORM
APN #J 26 `f-lf D Zo Date: 7/;2.5-/';2S . '
Building Address n JaK_
Owner's Nam Phone#:
Contractor: License #:
Contact: . Q wt �.cQ Phone #-
5 0>
Applicant/ n
s q1 12l 3 -L—
Building Permit Info:
Bld
Elect i. Plutnb Njech
o Description: '71-9 — 7,//6 0 0'
. .Residential: 4405�' `/d 4n t Commercial:
Sq.Fr. Floor Area:
3/ dv
Architect/Engineer: j Valuation:
/D. ASO' dZj
ype of Construction: Occupancy Group:
Qty, if
Applicable FeeID _ Fee Description Fee Group
BPERMFEE .? Bldg Permit Fees BUILIDNG
1 BSEISMICRE', Seismic Fee Res BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
. BPLANCAK ; Plan Check Fee BUILIDNG
BMITIGAT Housin Miti prion Fee BUILIDNG
BUSLIC ; Business License BUILIDNG
S ell /Z-3Z,
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