04090071 (2) CITY OF CUPERTINO
HUILDING DIVISION PERMIT �COIVTRACT;,0WINF0RMATION K-,
BUILDING ADDRESS: SIMON SAYS ROOFING PERMIT NO.04090071
M PERMIT ISSUE DATE
ONE: SANITARY OL NO.
ARCHITIR21YE gGINEER: BUILDING PERMIT INFO
L ELE PLUMB MECH
(�
X00 LICENSED CONTRACTOR'S DECLARATION
wF 1 umby affirm chat 1 am licensed under provisions of Chapter 9(commencing Job Descr I
2w with Section 70(Ngof Division 3 ofthe Business and Profeuiom Cads.and my licemt is
^<c in full homeland cffa
�'qi Lianss ctsas �3�1 Lic.N "7S`f`I REROOF W/ SHINGLES SEP 21 2004
ZFp Dam A�) �In y Contrutar, SIMM �/( t>< +�
q ARCHITECTS DECLARATION
a I understand my plans shell ha used as public records BUILDING
7yU
;0� Licenced Prichard...)
3OWNER-BUILDER DECLARATION
<I 1 hereby alfirm Nal Ism exempt from Ne Convacmrs License Law for the
00 followingmason.(Section 7031.5,Business and Professions Codc:Any city or county
y$ff which mquires a permit to construct.alien improve,demolish,or repair any someone
fza prior in its issuance,also inquires the applicant forsueh permiUo Glc a signed nmcmcnc
< Rod he is licensed pursuant to the provisiomnfthe Contractor's Laomse Law(Chapter 9 Sq. Ft.Floor Area Valu son
ytz-O (commencing with Section 7000)of Division Sof the Business and Professia iCode)or
i Nat he is exempt Ruminant and On basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for.permit subjects the applicant to penalty of
not mom mn fivhundred dollars $00). 3 gVVJt...tlerO O Occupancy Type
❑1.cot owner of the property,or my employees with wages as chair mile compensation,
will do the work.and the swnum is not intended or olfesed for sale(Sec.7044,Business
and Professions CaThe e Canoam
crme m
a Licelaw does dapply to se owner of Required Inspections
pmMny who builds or improves themnn,and who dins smh work himself or through his
own employees,provided Nat such improvements are not intended at offered for sale.If,
however,the building or orprevament is sold within one year of completion,Ne owner
builder will have the human of proving that he did not build a improve for purpose of
sale.).
❑1.as owner of the pmpi am exclusively conducting with licensed Commuters to
con.ruct none project(Sec.7064,Business and Pmfessiom Code)The Canuacmes Li.
cense Law docs not apply to an owner of propany who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to Be Contractors
License law.
❑1 an exempt under Sec ,B&P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent a self-insure for Worker's Camped.
satim,as provided for by Section 3700 of the tabor Code.for me performance of the
ark for which this permit is issued.
0'rk1 have and will maintain Worker's Compensation Insunna,as required by Section
J]00 of the labor Code,for the performance of the work for which this permit is issued.
My
CWork_ersCompensation Insurance carrier and Policy 0number am
center; Policy No.:eCGC1OFrPr10N :
112a���
FROM WORKERS'
COMPENSATION INSURANCE
Ghia senior need not ha completed if to Notaic is faro.hundred dollars($100)
o less.)
1 certify mac in the perfomunee of the work for which this Permit 0 issued,l shall net
employ any person in any manner so as to become subject to the Werken'Compcnudon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenilmilm of Exemption,you should
become subject in the Worker'a Compensation provisions of the Labor Code,you must
.JO forthwith vo
with comply with such provisions or this Permit shall ha occurred reked.
'Z CONSTRUCTION LENDING AGENCY
IMreby affirm mat them is a construction lending agency fm the erfco max,of
me work ler whim this permit is issmd(Sce.3097,Co.C.)
Under's Name
Lir
Under' Address
1
U Q 1 agree mat 1 have read this application and suis Nn the shove information miting is
Ftartan l agree m comply with all city and county Ordws 01 and suis laws relating m
uowncnnswcuen,and herebyauthonforeodues. tisusof Nis city to enter upon the n/l
W auvc(We)ond agree
vac saw for inspection keep ho
(We)agree to Save,indemnify and keep may
in an mC way
of Cupertino against
h liabilities,jnce of the creasingofpcnusmit. may in any way secret against said City
U ,Z APLICAnee ofinegranting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date t/
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaRDau
HAZARDOUS
S MATERIALS DISCLOSURE Type of Roof
Will the a Cu( nt or)njnofurore wilding e.Chapter
or handle Health an maunal
C defined by du Cupcnino Municipal Code.Chapter 9.12,and the Health and Safety
Cone.
Schen zss3xa)1
❑Yet 0N All roofs shall be inspected prior to any roofing material being
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
it hmafdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
isvict?
❑Yes ❑Nu
I have mad the hexamous materialsmquiremenu under Chapter 695 oflu Glifor-
ria Health&Safety Code=an
Sections 25505,25533 and 25534.1 ionic and Naz ifthe Wilding
no, unan4 that it is my rtsponsibilicy lm nastily the acupant of the ,
u tpsiarteissuanceofaCcmficauofOccup cy. IgOaI re Of ppllCanl'n 'C , �r.( 'F is t All roof coverings to be Class 'B" or better
Da
J
� Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0,� Fax(408)777-3333 UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
r Ccs cS �y 09 00-1
OWNER'S NAME: n �t�r }- PHONE #' 9-c, e a
GENERAL CONTRACTOR: S o,- Roo &L, FAX #
I am not using any subcontractors:VA '
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
Owner ontractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
IUPEkTINO Fax: (408) 777-3333
Building Department
I'
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 Name: rr� �X_J 0.�v-\ k-"'C h -f-
Job Site Address: S y S S
Roofing Company Name: Y f1 ISYS
A plicant's Signature: Date: 3 6�
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
NREROOF T o
CUPERTINO PERMIT APPLICATION FORM
APN# '-?:>L9 9 _a 5^Co-co
Building Address:/D
Os Name:/ , J Phone#:
V�rl ►�/01
Co actor: Phone #: License #:
rm n S oa �/-1 5 S31 •9700 ^79 -L/
Con Ph4ne#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ B ilt-Up rShoof
❑ Asphalt Shingles Asphalt ingles
mood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
%/ro be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
`T D ip j ns(�t IE> e V— tnS+A-1 I &G6 Z3
Residential Commercial ❑ IVISJ4 Q n
rCSICQ2t1 a� ,,,{)
Fire Zone: Yes El No Confirmed with Planning Det. if `�
there are any restrictions: LJ
Cost of Pr o ect: Type o Construction: Occupancy group:
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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