05050012 (2) CITY OF CUPERTIN0 +"^">'«-w%
BUILDING DIVISION PERMIT C,ONTRACTORIlVFO1ZMt�TIQN
BUILDING ADDRESS: PERMIT NO.920 D4c A VIAT ROOFING 5050012
OWNER'S NAME: PERMIT ISSUE DATE
,NE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
aWULICENSEDCONTRd under CON'TRACTOR'S DECLARATION Job Description
uF I hereby afOrm that 1 am licensed under proviuons of Chapter 9(commencing P
mW with Semion 10110)af Division 3af the Businw and Profcstiam Codc.arta myliccnu is FIIVA���
z<�„ i.full rare ante
n 2 REROOF W/COMP. Er`
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Lk.a
aF, Dale Cmdrumr
pp ARCHITECTS DECLARATION
y 1 understand my plans shall be used as public meet&
D�u
3 G t; Lactated Profesti.nal
an -7%3E 2005
OWNER-BUILDER DECLARATION
.�<2 1 hereby affirm that I am exempt from the Contmesor's License Law for the
HO e sons O following man.(Sudan]031.5.Business and ProfessioCode:Any city or county
5:(L which requires a permit m conumq alter,improve,demufsh,or repair any structure
Z taorwalicalrocilpaluntloft lW provisions
oftlac onge mittoceres,awpChmmcnt
< (comm,caned purttionT the of Division
afore eBuacmr'a Litenlaw(C Code)or Sq.Ft. Floor Area Valu hon
x�0 (commencing with Sectfrns and O basis n3 of theeged exempt Professions Cock)ser
y $ Net he u eub "appli and the basis for the alleged Gumption.Any violmlon of
mi gave,
7031.5 by ury applicant far a permit subjects the applicant m a civil penalty of
3 54�BY?�ig$eN 0 Occupancy Type
oat mart than Ree hundred dollars(sso0). P Y YP
0 1,as owner of the property,Or my employers with wages as their sale compensation,
will do the ,it.aad the auucmre is not intended at offered for sale(Sec.1044,Business
and Proportion Core:The,Commcmrs License Law does not apply in an owner of Required Inspections
property who builds Or improves thereon,and who does such work himself or through his
own employees,provided thmsuch improsereenu see Wtinmrbed or OBLaed furuk.If. '
however.the building or improvement is said within one year of ampleuon,the owner-
builder will haws the burden of proving Nal he did not Wild or improve for purpose of
sale.).
0 1,as owner of the pmpeny.am exclusively contracting with intend contriteness to
..,met the,project(Sec.71144.Business and Profestioos Cade:)Tac ContractrNs Li.
tong,Law dors not apply to an owner of property,who Wilds or improves thereon,and.
who contracts for such projects with a conuactor(s)licensed pursuant to the Coalractor's
License law.
0 1 am exempt under Sec. ,B&P C far this reason
Own Data
WORKER'S COMPENSATION DECLARATION
1 hereby Nmt under penally of perjury one of the following declarations:
1 haw:and w01 maintain a CaruBes¢at Consent to ulbiesure for Warkte
cYa Compe
satian,as provided for by Section 3100 of the Labor Code,for thatPerformance of tae
work for which this permit is issued.
0 1 have and will maintain Worker's Compemauon Insurance,as required by Section
]TOO of die labor Cade,for the pelforma ns,of IW work for which this permil is issued.
My WorkeLYs Comperuauon Ivuruee canner and Policy numbe;r art:
Cagier. e�^fn�- �llM Policy No.:-7L��T/RO
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Thu action need..,W completed if the permit is foresee handled dollars(SIM)
or loss)
1 certify Nat in the performance of the work for which this Permit is issued.I shall not
cmpluyany person in any manner u as ill become Subject o the Workm CompmgdOn
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject in On Worker's Competition previsions of the labor Code.you most
,JZ forthwith comply with such provisions or this Permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[—� I hereby affirm Nat there is a constnrcuon lending agency,far On performaax of
ai
On work far which Nu permit is issued(Sec.3W1,Civ.C.)
Ilei ALenders Name
Cz Lender's Address
U Q 1 certify Nu 1 have read this application and Stam this the allows information is
Is. F' ounce-1 Agra to comply with all city and county on inances and sure laws relating in
0 U Wilding construction.and hereby authorial,repRHataIIMS of this city to cater upon dM
FVafwvcmcmianca property for inspection purposes
y (We)agree to save,indemnify and kap harmless the City of Cupertino against
I,iZ liabilities.Judgments costs and ex pmtseassit. may in any way aerneagaimtuid City
U r2 in of OC UNDERSTANDS
ing of this per mit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Stgnuurc of ApplicanUCamrscmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant core or handle havndous material
M defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ale.Section 255320)?
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
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 harardaus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District P
❑Yes ON.
1 hast read the been tdlmsex a:rials requirements under Chap orK95 orthe Califor.
nice Ihahh&Safcty Codd,Sautes 255(15,25533 and 25534.1 undcretand thuifthe building
does not currently have a tenant,twat it is my responsibility in notify the Occupant or the
requimmcu,whlhmug IS,mel poor all issuance of a Ccniicale of Occupancy. Signature of Applicant Date
Owner or aulAomed agent ^"S All roof coverings to be Class"B"or better
Dam
F Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CRY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT# 0,5- dS 0 O) 2_
[7 9 20 Ac((-e ((,
OWNER'S NAME: PHONE# 2S 2— l G 6
GENERAL CONTRACTOR: - / FAX #
I am not using any subcontractors: 5—L —oS
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
f Building Division
J tisI City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY,OF Fax: (408)777-3333
4UPEkTINO
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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled
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: -,UL,
Job Site Address: .�-O 6) 10 Al
Roofing Company Name: :r
Applicant's Signature: 7,.. Date: $=Z_O$
Greg Casteel
Building Official GZG) S
Revised 11/2/04 0 /
Printed on Recycled Paper
CITY OF CUPERTINO
ag REROOF
CUPEf�TINO PERMIT APPLICATION FORM
APN # 3 S` Z Date:
Building Address:
Owner's Name: Phone#:
ST ti JqaQ e) ,117,
Contractor: Phone#: License#:
AILI P k 12L 9
Contact one#: Cupertino Business License#:
"r OV. 914, 255—
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
V 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: ON
Job Description:
r o � � ! oI co
Residential ® It
C mmercial ❑.
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: U
Cost of Project: Type of Construction: Occupancy group:
IQ 00 o
Qty. if
A licable Fee ID Fee Description Fee Grou
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
( BUSLIC Business License BUILDING
Y
2� Z . S