04060106 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CO NTRACTOR'INFORMATION
BUILDING ADDRESS: T D� ROOFING PERMITN°04060106
107
OWNER'S NAME: PERMIT LSSUE DATE
Alk MICHELLE LEE 3540 MARGATR AVE or 11 dll?no4
OPIONE: SANITARY NO. CONTROL NO,
(4 08) 892-8872
ARCHITECITENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a°ioo LICENSED CONTRACTOR'S DECLARATION
< G I Mushy affirm out, de
xI am licensed unr provisions of Chapter 9(commencing IOI7 DOS0pt,
U with Sdon7(IW)of Division 3 of the Business and Professoriat de
Co .and my license h u
z,L1 in 0.111 adeffegl C. tee x �C3 F3 a3 REROOF
Z;, Date Gantmeror — JUL 2 2004
h ARCHITEC'T'S DECLCRAI'ION
'y5
1U 1 understand my plans abet W used as public..am
30� Licensed Pmfeanonel BUILDING
OWNER-BUILDER DECLARATION
1 hereby affirm Thal I em exempt farm the Contractors Lima.Law far the
ore following mason.(section IID 1.3,Business and Profcstlans Code:Any city of county
as$ which requires a Permit to concord,alter,improve,demolish,or repair any svucture
''I'•r^ prior to its issuance,also requires the applicant for such Permit to file a signed statement
Nat he is licensed pursuant to the provisions of the Caso.tuh License Law(chapter 9 Sq. Ft. Floor Area Valuation.
(commencing with Saurian 7000)of Division 3 of the Business and Professions Cadc)ur
y Net he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Me applicant o a civil penalty of 3"N2,0uhter00 Occupancy Type
not mare Nan five hundred dollars($500).
❑I.u owner of Ne property,or my employes with wages as their so to com'mishan,
will do the wart.and the swan¢is not intended or offered for side(Sec.70,sx,Business
and Professions Code:The Contraction License Law does not apply to an owner of Required Inspections
progeny who builds or improves thcmon.and who dsmseuch work himself or through his
Own employes,provided Met such improvemenune not intended orofferW forsde.IL
however,the building or improvement is sold within one year of completion,Ne owner.
Wilder will low the burden of moving that W did not build or improve for purpose of
axle.).
❑1,as owner of the propcny,em exclusively contracting with licensed convectors to
costroct the Project(Sec.7014,Business and Profssions Code:)The Conhazor's Li-
come law dean nos apply to an owner of property who builds or improves thereon.and
who contracts for such projects woof a em ractor(a)licensed pursuant to the Cmn=tOeS
License law •
[21 am exempt under Sec. .B Af P C for this earned
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of Ne following accountants:
I low and will mountain aCeadficeo of Consent o sell-insure for Workers Comrcm
cation,s povided for by Section 37W of the labor Code,for Ne performance of the
oro for which Nis permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
3 ofthe labor Code.for Ne information of the work for which this repair is issued.
My Workrrs Calmp mora n Insurance alInico and Policy number are: � �`
Ganite C"1 cuts s C\ Polity NO.: 14� 1 2.S_ a
CERTIFICA FEKEMPION FROM WORKERS'
COMPENSATION INSURANCE
mins=am need not M completed if the leemit is forma,hundred dollars(SIM)
aro less.)
I certify that in the Performance of the work for which this Permit a issucd.I shell not
employ any person in say mamaoso as to become subject to tM Workers'Comresation
Laws Of California,Dam
Applicant
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
Woman subject to the Worker'a Compcmation provisions of the labor Code,you must
.JO foMwiub comply with such provisions or this pc.it Mail be demand mwkcd.
zoCONSTRUCTION LENDING AGENCY
(-e I hereby affirm that them is a ecosuuctinn lending agency for Jae urformance of
a> dm work fur which this permit is issued(See.3097,Ci,C.)
0 Lenders Name
a z Lender's Add=
V C) I citify that I have mod this application and sole that oft above information is
F comma I agree to comply with all city and county ordinances and slam laws relating to
0 V building construction.and hereby authorize repesenulivs ofthis city to enter upon the
�fel aWw-memimmil property for inspection or;vm...
,^y (We).,me to save,indemnify and keep hamless the City of Cupar me against
r, Iiabiliticajudgmenu,costs and expenses which may in any way accrue against mid City
C)z APPLs permit.
ICANTOUNDERSTANDS Aof Me gaining of hND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE E ILATIONS.
g{ K.!4le;, I /II6l! Re-roofs
Signature of ApplicanUContmoo rue
HAZARDO 5 1ATERIALSDISCLOSURE Type of Roof
Will the applicant or forum building aeeupantslore or handle hvardous material
Us defined bythe Cupertino Municipal Code.Chapter 9.13.and the HcaIN and Safety
Code.semmn 25532(ap All roofs shall be inspected prior to any roofing material being installed.
Dy. u
Will Ne applicant or future building Occupant tax equipment or dcvicca which If a roof is installed without first obtaining an inspection,I agree to remove
Omit hazardous air commeanarm a defined by elm Bay Arca Air Quality Management all new materials for inspection.
Diatricl7 /
❑Yes
1 have read the haardmmsmvcrials requimmenu under Chapter 6.95 of Ne Caltror- // I�
nimHcalth&Sdcsy CaM.Sccdoro 255(15.23533 and]5534.Iundcrstand thwW building /U Ll,Vlr /, y /C k-
dos not cu ��n�ppppy hdvw d tenant,oat it is my respoosihility to notify the Occupant of Me
mquimrc^u wgien ¢bcmelrriormissuaaecofaCinifirateofampp.nmy. I Signature of Applicant Date
ownerramthodcdegem J Date All roof coverings to be Class"B"or better
Community Development
r 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
UPERTINO
Building De artment
JOB ADDR$SS:
s a PERMIT #
10 � G SS �2� dkr C� L, C7 6 o ' 0 �
OWNER'S NAME: )c e ( ( ,2 Lz-Q- PHONE 4�g q Z
GENERAL CONTRACTOR: I FAX #
i
I am not using any subcontractors: Ka. 6 I q c-±
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/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY Of Fax: (408) 777-3333
IUPEkTINO
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 Name: _ M " c [I e I/.e Le-9—
Job Site Address: I O :�G, R 1nj F &f ('_tcs
Roofing Company Name: ( D Izl
A plicant's Signature: Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOFam,
b o l
CUPERTINO PERMIT APPLICATION FORM
APN# 3 co Cl a d 3 L,( Date: 6 t 4 0
Building Address: 'O
168 W
Owner's Name: I Phone#:
,V1C Q e �e Q_ a 55 - q 6 I S
Contractor: r Phone #: License#:
i D 1Zoo } n (uo3) Sq � (0 6 6 2 D
Con ct: Phone #: Cupertino Business License#:
e S. o SC) S S �-
'Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof y❑� Built-Up roof
El Asphalt Shingles /C Asphalt Shingles 3 0 .I CS copo �>
k 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 Polic
Job Description: �
.k1R'rn o J e W o o ck S (A 0.y a-SL CA.c.,t vJ / 30 j r C-4-D-)'� f S
Residential Commercial ❑ t 6 U S B
Fire Zone: Yes ❑ No IM Confirmed with nning Det. if
there are restrictions: LJ
Cost of Project: Type of Construction: ccup cy gr
. rn
Qty/lf
ApelicAble 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