03070077 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 4CONTRACT•.OR INFORMATION "
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(415) 493-6373 ILDINCADDRESS: COSMOS ROOFING """'*03070077"""'*03070077OWNER'S NAME: 1901 OLD MIDDLEFIELD .WY PERMIT ISSUE DATE
ONE; SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
up LICENSED CONTRACTOR'S DECLARATION L� LL1� v....l'�
w FOF I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Des ript10n r
Fit3 with Scoti..7MM))of Division 3ofthe Uusinasatd Professiom Codc.and my hot.is
,pH in mu tome and cf t '�. 8'S �'� REROOF JUL gl 2003
? License CLle.N
Dam Cunt cod'
£4 ARCHITECTS aDECLARATION rpt/+
�W I understand my Pl ..us,hall W usedpublicmeool.
BUILDING
pa
5� Licensed Pmfesximil
GNER-BUILDER DECLARATION
f 1 hereby strips Nm 1 em exempt from the Contractor's License Law or the
_p O following reason.(section 7(01.5,Business and Professions Code:Any city or county
which m4onct a Perrot to construct,alter,improve,demolish,or repair any atrnemm
pnmm its issuance,also requires she applicant for such Pcrmitto file a signed statement
mm< that hcislicensed pursuant tothe ptivisions(if the ContractorsLimsto aw(Chapter 9 Sq. Ft. Floor Area Valuation
rl-$ (commencing with Section 701(1())of Division of the Business and Profcssinns Code)or -
[t that he Is exempt therefrom and the basis for the alleged exemption.Any violist of 34214111 . 00
Section 3051.5 by airy appliesnt fon permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not mom don fns hundred dollars($500).
❑ I,u owner of the property,or my employees with wages u their sole compensation.
will do the work,and to income is not intended or offered for sale(Sec. Business 305 FRUME
—
and Professions Code:no Com uchn's License Law door not apply in an owner of Required Inspections
property who builds or imprnws Hereon.and who does such work himwlfcr through his 307 - INSULATION
own employees,provided that such improvements arc not intended or orfered(or sust.If. 601 ' — ROOF TEAR OFF
however,to lmilding of improvement is within one you of compound,the ownco-
builder will have the burden of proving that he did not build or Improve for purpose of 602 - ROOF PLYWOOD NAIL
sale')' 603 - ROOF BATTENS
❑1,as owner of the propcny,am exclusively contracting with licensed contractors to
coauucnhe project(Sec.7G&L Business and Praressions Codc:)The Commcmrs Li. 604 — ROOF IN-PROGRESS
exist,Law docs not apply to an owner of progeny who builds or improves themon,and
who contacts for such p ejects with a contracon(s)licensed pursuant m the Co Ionto'. -
License Law.
❑I am exempt under Sae. ,B&P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under Penalty of injury one.(,he following declarations:
I It.-and will maim.in a CeniMam u
of Consent wlf-inam for Worker.compete
mien,a provided for by Section 37W of the labor Code,for the performma or the
w ret for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by section
W of the Labor Code,for the performance of the work for which this permit is issued.
y Work-AC.0gfensuni Insunntt nrticr and Policy
�naumberno:
Cartier.-NZ �s•'—r Policy Na /1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseetion need not hecomplowd if the permit is fnrond hundred dollars($100)
or Ices.)
I comfy that in the performance of the work for which this Permit is issued,I shall not
employ any Person in any manner at or m become subject to the Worlecri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.afwr making this Ccnifrcaw of Exemption.you should
become Subject m the Worker's Compensation provisions of the Labor Code,you must
.J z forthwith comply with such provisions or this Permit hall M doomed revoked.
Z 0CONSTRUCTI ON LENDING AGENCY
— I thirchyshame air,.Nat dwreiu eoatnwtinn lending agdmy or Use Pcrfurmantt of (✓ —
CL> the work for which this permit is issued(Sec.3( ?.Civ.C.)
de
W Q Lsnr' Name .
D z Lenders Address
U Q 1 certify that 1 have mad this application and auto that dm above information is
Fcorrect.I agree to comply with all city and county ordinances and state laws misting w
0U building construction,and herebyauthorise mpraenutims of this city to enter upon the
G ahovo-mentioned proarty,for Inspection purposes.
(We)acme to ave,indemnify and keep outsold.the City or Cupertino against
ti N
liabilities,judgment,eosu and expenses which may In any way accrue againnsaid City / -
U Z in consequence of the gaming of this Permit.
APPLICANT UNDERSTAND�J.NB-11(ILL COM��IIL..Y WITH ALL NONPOINT Issued by: Date
SOURCE REGULATIONLtQ I .M/l o r6�
•(J�� ( / Re-roofs
Signature of APplicanVConmcmr1110
Got
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle h unamous material
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scctirn 25532(a)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea p p ' y s g '
Will the applicant or future building tecupant use equipment or devicor which If a roof is installed without first obtaining an inspection,I agree to remove
It ho'mrdnm air contmninano as defined by the Bay Area Air Quality Management all new materials for inspection.
«�
❑Yet ❑
I have reW the haardWs materials m loremenu under Cooper 6.95 or the Calif.,.
nia Health&Safety Code.Sections 25515.35533 and 25534.1 undersand that ifthe building _71)v
dens not currently haw a moans Nat it is my msponsihil ity to nndfy the accuPat of the
myuire" whi���'�°}tett prior wisstyyq�s ofa Certificate:of Occas dr. Signature of Ap Kant Date
O - —L- �O�L 7ll�V�S
Owner onwhorimda t to All roof coverings to be Class"B"or better
Community Development Department
Building Division
� City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
fUPE' kJ1N0
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: �R/Ln/u %� C.,04 a(s��y� -
Job Site Address:
Roofing Company Name: e,,V t.v o �*_
A plicanYs Signature: " 10 O3
eel Date: 2
\�ll4tilh10LY� I�
Greg t
Building Official
Revised 1/30/03
Printed an Recycled Paper
1
CITY OF CUPERTINO d 3 0 7 n a 77
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# n I Date: _00103
LafD
Building Address, O
Owner's e* Lin Phone#
�S593
Contractor:12 Phone#: License#:
6.52 94IF= 64-3 7IsVs�/
Contact: Phone#• Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )(- Asphalt Shingles
`K Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Nkmber 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:Ta S,14,& � 74 Vss, 3e-f�. Qow
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
131 )2-3 • n
if
h 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
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