04080199 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT,ORANFORMA' ION ,
BUILDING ADDRESS: JNSJ( ROOFING INC PERMIT"D04080199
OWNER'S NAME: PERMITISSUEDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EIfCr PLUMB MECH
0 0 0 0
.0, LICENSED CONTRACTOR'S DECLARATION lobDescri IIOn
ZC 1 hcmhy affirm Nat 1 am licensed under provisions of Chapter 9(cnmmcncing p
<b with 5emion]IXNq of DivisionJof the Busincv and Professimss C^de.end mylicenx is
ow in full forte andefgz REROOF W/PLY BUILTUP
DLIZ Liccnx Lie.N
�Fp Dam TEContnnm�_ S
smailh use DECLARATION
a I understand my plans shall be used or public mmrds
io t; Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hcmhy.(firm that 1 am exempt from Ne sionsCContractor's License Law for the /
O o following rias a (Section](131.5.Business and Pm.derr li Code:Any city of county
E.
which requires a Kenn to construct,alcor.improve,demnlW,or repair mY+venom
prior in its issuance.and requires Ile applicant forsuch permit to Ole a signed statement
tb'< (hu he is licensed pursuant to Ne provisions of the Contractors License Law(Chap¢r 9 Sq.Ft. Floor Area Valuation
US (commencing With Section 7")of Division J of the B usinus and Profusions Code)or
y _
that he is exempt therefrom and the breis for the alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjecu the applicator o a civil penalty of 32VNGt"cr00 Occupancy Type
not mart dm Ove hundred dollars(5500). .
❑1,u owner of the pmpeny,m my employees with wages as their sole compensation,
will do the work and the structure is not intended in offered for sale(Sce.7044.Business
and Pmfessions Code:The Contractors License Law docs not apply to an owner of Required Inspections
property who builds or imprrvets themon,and whodoes such wmkhimxlf orthmugh his
awn emplaYas,pmvided that such improvements art not intended orofferW presale.IL
however,the building or improvement is mid within one year of completion.the owner,
builder will have Ne burden of proving that he did not Wild w improve for purpose of
al.)
1,a owner of the property.❑ Se pe 4 .B aelusi no convening with licensed rontr uor's i-
cm se,La de pmjcct(See.7044.Business and y who
Code:)The Convector+Li-
enee law dors not apply b an owner of pmpeny who Wilds or improves themon.andcontracontractswhcontractsfor such projects m
with a canctar(s)licensed pursuant to thCo
e Conlnnor's .
Liccnx law.
❑I am exempt undo Sec. .B&P C 0r this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
I hose and will maintain aCenifiam of Comment in self-insure for WorsaWsCompcn-
satum,as he vidcd for by SCC4an 3700 of the labor Code,for de pcAmco nce of IW
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for Ne performance of Ne work for which Nis peman is issued.
My Wore �ofir or and Polity number art:
Cartier. Polity"a.:,Cc,
'
01"U�v
C� Pf11RWORKERS
COMPENSATION INSURANCE
mos section need notbecompmed if the permit is for one hundred dollars($100)
or Icss.)
1 certify that in thc performance of the work for which this permit is issued,1 shall not
employ any penton in any mannerso a w Wmnte subject to the Workers Compensation
Low s of California.Dom
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you Should
become subject in the Workers Compensation previsions of thc labor Code,you mum
Z forthwith comply with such provisions or this Permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[� Ihcmby Nitmshot ft.is a Comuuction lendingagcncy for the perfurmaac of
a the work for which this permit is issued(Sec.3097.Ci,C.)
W Q lender's Name
D.
L)Z tenders Addmv
()0 I certify That 1 have mad this application and sum that the salve informant.rmau
W t"' enrrtn.1 agree to comply with all city m0 county ordinances and sum laws mining US
e
�(7 abovengconsnedproand hereby authonprpoeunutivesof this city to enter upon the
above-mentioned property,for inspection proposes.
talc)agree I Saw indemnify roti keep harmless the City of Cupertino against
F" (n Iiablidu.judgmc .c umd u"On's which may in any way aarw agaimuatd City
O Z inconsequence c anting of Nis permit. t
^ APPLICANT D RSrANDS AND WILL COMPLY WITH AL NONP Nr Issued by:S4t&W Date
SOURCE RE ONS.
Z Re-roofs
Sign f pian eat racmr Dail I
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will(W applicant or future building oceupanumm or handle haardous material
critical by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ode,sElYees zs53x(a)] �a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or minm building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haraedous air mnmminanc JcfncJ by the Bay Area Air Quality Manegtmcnt all Bew maters s for inspection.
Di3lliel]
❑Yes Nu
Ihavc mad theh-a duusmaerialsrequimmcntsunder Chaper6.95ofthe Califon �� O
ma Hcalthd SafetyCade.Sectiom25505,25533 md15534.lundersunddernifthe Wilding
does not Curren y hyc a Terson(,that i1 u my responsibility m nuuly Ne occupant of the -
mquiemens t Mus(bemetpriorwismmm.(.Certifcaeof apmcy. Sig a[ Applicant D e
ow r anthorivedgm( Z D.m All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
! � Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: « PERMIT #
0 D V 8 0 /
OWNER'S NAME: bN, AW'ZA- r-S PHONE # yog
GENERAL CONTRACTOR: 3IJ514f FAX #
I am not using any subcontractors: Z 3 C
Signature Date
Please check applicable subcontractors d com Tete 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
.2,-3 0
r/Contractor Signature Date
Community Development Department
It
Building Division
„ - City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
\ Fax: (408) 777-3333
RUPEkTINO
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:
Job Site Address: b �a �(M'"C G "
Roofing Company Name: I)S S T
A phcanYs Signature: Date: W
6l/
Greg . teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO ,I n�D I qq
REROOF o p ll�
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # 3a _ I O _ USS Date: 3
Building Address: t( tl
o o c,-t-
ner's Name: Phone #:
�,Yvzx pn cS
Contractor: Phon #: License#:
�NsS 4�_ �� �4a�� 2�a -����
Contact: P ne# Cupertino Business License#:
�rh S Leel M)
Type of Roof Covering:
Existing: Proposed:
Built-Up Roof Built-Up roof
❑ Asphalt Shingles ❑ 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 Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
T,&^y 49Z Sxts ws�o ll
Residential ❑ Commercial Pk
Fire Zone: Yes ❑ No ❑ Confirmed with.-lanning.Dept. if
there arer I
restrictio : LLJJ
Cost of o ect: ao Typection: Occ ancy up:
55
Qty..
A fic•ble 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
z� 7 9