04080135 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT Ci)N�TRACTOR,IN ORMATIbI ,
❑UILDING ADDRESS: FOUR SEASONS ROOFING PERMIT ND 04080135
OW NEWS NAME: PERMIT ISSUE DATE
ONE:
—I-RNING ST SANITARY O. N ROL NO.
ARC HT EC/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0
u o o reel H is
LICENSED CONTRACTOR'S DECLARATION Job Desc ti D
C I hereby affirm that I am licensed under previsions of Chapter 9(commencing I'
<U withis lion]Q11puf Divi.um3of Ne Basin sand Professions COJe,andmylicenuis U
�„ in re me anderredt. �1 -1- 0, REROOF
g z uee�Claes C 3 c.If _
a-� Dam ClinometerUva. ¢u' .x Ax SEP U 2004
ARCHITECTS DECC{{..AggATION
< I understand my plans shall W used as p w recnNs
U LD0N10
+3.ON Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hmaso affirm that 1 ore exempt from Ne Comment's Co License Law for the
BE E00 O following mason.(Seton](131.9.Business and n,demolish,
Code:Any city or county
k m whichmamma
its i soma..fret.re construct,the alma improve,h pormsh,m repair any sesame
y"v1 pliaroiucensed,osentto the lhcvisiorant forme sucContractor's
oiense Law(Chncd mmcm
Nothe menccenscdpursuant tot)of Division 3NeComsinesssndPrmisio(s Code)or Sq.F[.Floor Area Valua[on
FFG (commencing with section 7")of Divisinn]nhhe Business end Professions Codc7ur
i Nn he is exempt temfrom and We basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 34V442fttgr00 Occupancy Type
not more Nan five hundred doll..(1500).
1,as owner of the property,or my employees with wages as Nair sole compensation,
will do the work,and On swnure is not intended or offered for stile(Sec.7IH4,Business
and Professions Code:The Contractors License Law does nut apply to an owner or Required Inspections
pori who builds or improves thereon,and whodoessuch work himselfort enough his
awn employees,provided that such improvements an not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contracmrs to
construct the project(See.7044.Business and Professions Code:)The Contractor's Li _
cense taw docs not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
0 l am exempt under Sec. ,B&P C for this reason
Owner Date
AkWORKER'S COMPENSATION DECLARATION
-A licreby affirm under Penalty of perjury one of to fallowing declarations:
aW 1 ha va and will maintain a Cunificam of Consent to self-insum for Worker's Compcn-
saion,as provided for by Section 37W of the Labor Code,for to performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of to work for which this permit is issued.
M�yy Worker's Compensation insurance(fcarrier and Policy num W
c5sadvA-�1n5ucc.Ke,Co of+,a�e�Paohcy No.;WL SG Y
✓ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sc flon need not becompleted ifthe Permit is return hundred dNlxrs(IIM)
,it less.)
1 cenify that in the performance of the work for which this permit is issued,1 shall not
employ any Person in any manner so as in become subject o the Workers'Compensation
Laws of California.Date
Applicanl
NOTICE TO APPLICANT:If,after making this Cenricate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you..at
O forthwith Comply with such provisions or this permit shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(r I hereby aRrre that ten is a construction lending agency lot the Performance of
Ri the walk fur which this permit is issued(Sec.300,Civ.C.)
GA Lender's Name
z Lender's Address
V 1 certify that 1 have read this application and sum that the above information is
F correct.I agree to comply with all city and county ordinances and sum laws relating to
C V building construction,and hereby anhoris representatives of this city to enter upon the
C shovcmemiunc l properly for inspection purposes.
(We)agree a save,indemnify and keep harmles to City of Cupertino against
r h
fair lidec,judgments,costs and expenses which may in any way second against said City
U z APPLICANTeUfthe grarningµSTAN of this permit.LL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE RE LAYIONS (yD-
��\ 6_ � ?"" Re-roofs
Slgnet of APPllcantlContract Date
HAZARDOU ERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stare or handle hauus material
as defined by to Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Senion 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes pynu
Will the applicaa or future rc building occupant use equipment or Jcvices whicM1 If a roof is installed without first obtaining an inspection,I agree to remove
it hasardeus air cnn0minantsyas defined by the Bay Area Air Quality Management all new materials for inspection.
shout
❑Yes No
1 have mad the havardous materials requirements under Chapmr6.95 of the Califnry T`
ria Hdehh&Safely Cade,Sector 25505,25533 and 25534.I understand drafthc M1uilJing Qom— T —I-7-0
does not cunxi�i11ly have a nam.that it is my responsibility to nndry the occupant of the n ��7711�` `ate
myuircmcWtEshiayn mu m pnar},n isuancc oft Ccrtificam of Oce"��c. ignature of Applicant �f/cte
L8-ate All roof coverings to be Class I-ik`/or better
Owner ser autodred agent 1 pant
Community Development
10300 Torre Avenue
Cupertino CA 95014
BEV Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTIN®
11'aluilding Department
JOB ADDRESS: PERMIT #
10111 0ti0 $ 813S--
OWNER'S NAME: p ab S 7o PHONE # 'Z-7 ? -G33G
GENERAL CONTRACTOR: b,A r S e-&S O^S FAX #
v
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
66 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 FSeG on _ao�' -I-z- O
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner Contractignature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
C U PEkTINO
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 Y4"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: f D l /" oLa o/ r 14-j-ems . R LJ
Roofing Company Name: —
Feln
rr—
A "cant's/Signature: _ate: /(-D�/
Is \N6IADLX� L
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO0
REROOF T
CUPEfkTINO PERMIT APPLICATION FORM
APN # jt-i 2- Ll IL C)O S Date: O
Building Address: n
l0/ 17 ana�li9/r�rf S 1.,nre, Elvd
Owner's.Name: QPhone#:
olo�tn5 ; `�vhn Z '1 `� —G3z,U
Contractor: � Phone #: License#:
12
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles >ia=-Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
Ce 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: �^ A
✓h�K% {' L-G✓�L[/L Iii L-� /'� '�'1 r
Residential Zj , Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Constructi Occupancy group::
rW
Qty. if
App 1 / 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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