05010076 (2) CITY OF CUPERTINOs
BUILDING DIVISION PERMIT CONTRACTQR INFORMATION :
BUILDING ADDRESS: T D ROOFING PERMIT N®5010076
7e] MEDINA LN
OWNER'S NAME: PERMIT MU DATE
FRANKLINX MAR T 01/12/2005
ONE: SANITARY NO. CONTROL N0.
408) 892-8872
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±oo LICENSED CONTRACTORS DECLARATION
of CON
mp hinny BErmthat1amfth.Bdunderprovisionsof,Code, 9(commencing Job Descriptio
;�R with Scorion]Olkq of Division Bof the Business and Professions Code,and my license is
n roti mree dery 3q �a REROOF W/COMP.
j,O n Lianx Cl Lica /
-�O Date 1 rS DEml
pp ARCHITECTS DECLARATI `
c c.u 1 understand my plans shall bo used as public records
[ y
a°d
Licensed Professional V
7 OWNER-BUILDER DECLARATION
il Y I hereby maso affmm that I am.Burin from the Coons Co License Law for the
ScO followingmason.a permSecit t 7031.5.sr.Business and sae,dinions Code:Any city or county
_ which requires a e,also to stir s,the alter.improve,h Permit t ore a airsig any swctum $8500
.iy
prior to issuans,alsu requires the applicant for such Permit BlcasigncJ tutamen
<
I hat Im is licensed pursuant to the phivisions of the Contractor's Liecisc Law(Chapter 9 Sq. Ft. Floor Area Valuation
(Commencing with Section 700d)of Division Sof the B usiness and Profeasions Codc)or
— that he is exempt themfmm and the basis for the alleged exemption.Any violation of �a�run 2��
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3[YY13\010IUPWeli 0 Occupancy Type
not more than fin hundred dollars(S500), p y yp
1,as owner of the propeny,or my cmploycu wish wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7W.Bulinus
and Professions Codc:The Convector's License law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
own employees,provided Ihm such improvements are not intended oroffcrcd leisure.IL
however,the building or improvement is sold within otte year of completion.Ne owner-
builder will base the burden of proving that he did oat Wild m improve for purpose or
sale.).
❑1.as owner of she propeny,am exclusively contracting with licensed contractors to
construct she project(Sea]Oaa,Business and Professions Cade:)The Convactur's Li
cannot law does not apply to an owner of properly who Wilds or improves thereon,and.
who contracts for such projects with a convactor(s)Iicertsed pursuant o the Contractor's
License law.
O 1 am esempt under Sec. ,B&P C for this reasonjwn- —
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 him and will maintain aCer ifcate of Cmucnt to ulf-home rue Workers Cwnpcn.
station,as pmvided for by Station 3700 of the labor Code,for the perfom ince of the
2wor for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as uquircd by Section
3700 of the labor Cade,for Inc performance of the work for which this permit is issued.
My WorkeleCpmpensation in On ea ser and Policy number am: ,�'7
Cartier: S q / Ul Policy No.: I a�i2"j1 - k�
CERTIFICA OFEXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed irthe Permit is formic hundred dollus(Sloo)
,it loss)
1 unify 0-1 1-the relformanec of the work for which this permit is issued,l shall not
employ any person in any manner an as to become subject o ted Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:Ir.after making this Ce offline of Exemption,you should
become suhjco to the Workers Comps nation provisions of the Labor Code,you most
�z forthwith comply with such provisions of this Permit shall W teemed mvnkcd.
z h CONS fRUCrION LENDING AGENCY
IMonday union that them is a construction lending agency for NC Performance of
> the worMonday for which this permit is issued(Sce.)B9].Civ.C.)
+1 Q Lender's Name
7 z Lender's Address
..)Q I ennify that I have mad this application and state that the above information is
y H
contact.I agree ro comply with all city and county ordinances and state laws relating tb
�U building constmetion.and hereby authmive representatives or this city in enter upnn tM
W abovemS.judg dproperty for impaction expenses
purpowhich m.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
t/1 in fiabil
or
costs granting
expbnxawhich may in any wayaccme against said City
il
..)z A APPLICANT
of due UNDERSTANDS
of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT slued by: Date
SOURCE REGUL T S.
o Re-roofs
Signature of App cant/ iam"ohn Dru
HAZARDOUS MATERIA ISCLOSURE Type of Roof
Will she applicant or rune building bee to store or handle hanrduus material
as defined by the Cupertino Municipal,Code,Chapter 9.Iz,and the Health and Safay
,dKrode,lem
Nu on zssyz(o? All roofs shall be inspected prior to any roofing material being installed.
E3`_Tes
Will Lh epplibanlo furore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II ha2rdous air contaminants as defined by she Bay Area Air Quality Management
in? all new materials for inspection.
v
❑secs No
1 have mad the hanoba s materials requirements under Chapter 6.95 of theCali Ear
-
iiaHralsh&Safcry Cbdc,Sections 255o5,255 mi,io85BC.luomil,denceshe Wilding �//� ;/
does not cumpntlffid 'em
nant.Nat it u my responsihility m nntil'y the aevpant of the
rcyaircrnentswhimm ' r xissuancc ora ccrdfca or Om r' Signature Applicant Date
c O
owor,or auth Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTOR NFORMATION:�°.
BUILDING ADDRESS: T D ROOFING PERMIT"05010076
29.7(;2 MFT)TNA TN
OWNER'S NAME: PERMIT ISSUE DATE
jilhFRANKLIN XU le;4n MARCATF. A1117.
NE: SANITARY NO. CONTROL NO.
(408) 892-8879,
ARCHIT IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MW14
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION lob Description
I Wreby affirm that I am Bcare d under provisions of Chapter 9(commencing p
with Sneuon 7")of Division 3 of the Business,and Professions Code.and my licevc is
c' inraumme .der, b J teas l� REROOF W�COI\'1�.�
j�a Lkmnw Cl V ® I
Date I 17,1 T'SDE ter
ARCHITECT'S DECLARATI
UI understand my plans shall W usM as public reewds
too Licensed Profussional
3 OWNER-BUILDER DECLARATION
F I hereby affirm that I am exempt from Js,Canlnnots U;cenw law for,he,
o O following mason.(Section IID 1.5,Business and Professions Cock:Any city or county
99 which require a permit to coruwct,a@a bnprow.demolish,or motor any structure
FZ< prior to its issuance.also penurious the applicant for such Permit to rile a signed statement
that he is licensed pursuant to the provisions of the Comnons'slJmmon
claw(Chapter9 Sq. Valuation(commencing with Section 7")of Division 3 of the Business and Profusions Code)or
H9 that he u exempt thenfwm and the huts far the alleged ea erpuan.Any viohfion of
Section
e mo7031.5
m31.brm y any
y apcaicant for.
Permit wbjxu the applicant to a civil penalty of 3 4' et0 0 Occupancy Type
❑I.ssawner of the popeny,wmy employcca with waguss Nab sole compewJon,
will do she wart,and theaWm..4.1 in ande l oraRcrem forlak sac.7W.Business
and Profession;Cade:The Co.=,.,i Lime law does not apply to an awns,of Required Inspections
propeny who builds or improves thereon,and who does such work himself or through his
own employm,provided that such improvements are notimrnded aroRered forsale If.
howewf.Ne building or improvement If sold within one,year of completion.the owner-
builder will base Ju horde.of moving had he did an,build or improve for purpom of
sale.).
❑1,as owner of the propcny,am ucluavely contracting with IlccnsM conuactws to
construct the poject(Sec.7014,Business and Professions Code)The Contactara Li.
cense Law dura not apply,o an owner of property who Wilds or improve Merton,and -
who contracts for such projects with a commelar(a)licensed pursuant to the convectors
License law.
0 1 ran antept under Sec. ,B ds P C far this mason
�#n °arcDECLARV O I D
WORKERS COMPENSATION ATION
1 hereby affirm under penalty of perjury one of Ne following dommatiom:
I ham and will maintain a Certiriurc ofConwm 1.self-inure for Workers Compem
moon,r provided for mi Section 3]00 0(the Inbar Code.for the performance of the
work solum,r Provided permit is eissued.ETI'
haw nod will maintainhe Cohn Come of thenhwor which
per by Section
My of k e a qp. ..d.a Nc peafmmance ter the work for winch Nis permit is issued.
My Workels mpcnsauon lnwnntt cortico and Polity number am;
er.
Carri _ �1 <\ •k\llo� Polity No.: (4-11 t J
CERTIFICATE F�Pf10N FROM WORKERS'
COMPENSATION INSURANCE
(ndusecum need wt W complmul trust,fernit is Roche hundoddollan(SIM)
or kss)
I cenify that in the pcfformance or the work(a,which this permit Ls issued.l shall not
employ any pawn I.any manner me as a became abject so Ne Workers''Compenuuan
Laws of Cal;foraln Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcale of Exemption,you should
become subject o the Workwi Compensation provisions of the Labor CMB,you muss
.JO faMwlth comply with such provisiom or this Permit shall ton Leaned revoked.
Zvy CONSTRUCTION LENDING AGENCY
,4 I hereby alarm Net Jere is a rotutwction lending agency for the Performance of
a the work for winch his Permit is issued(Sal.3097,Civ.C.)
W Under's Nunn
z Lsnderi AM.
U O 1 cenify that I have read this application and sato Nas the above information is
W f' tonna I agree to comply with all city and county ordinances and state lave miming to
0V building coutruction,wd hereby authadas rcpoemmutina of this city o env upon do,
Wvc.
uon
�a addlid tinned PropANIRSTANDS
a for ianpc pans purmwhich ms
(We)agme ro wvc,indemnify and keep harmless the City of Cupertino against
Foe f/1 IiabiliJu.judosu antl expcmu which may in any may attwc against said City /
f,z in comcq rinning o(Nis pcnnit.
^ uAppncc, CA AND WILL COMPLY WITH NO POINT Issued by: Date
�ENS.
i- f l O Re-roofs
SignuumorApplican Contracmr ak
HAZARDOU ATERIAIS DISCLOSURE Type of Roof
W;II Js,applicant w fuwm WJtling arupwutam or Mndto hanftlous..mom
va dcfi ed by the CUPmtinn Municipal Code,Chapscr 9.12.aM the Health and Safety
odc.Scceon 25532(a)?
❑Yna ` All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,ection,I agree to remove
Will Ne aPPIleant or future building occupant use equipment or devices which
_mit toewolous air contaminants as defined by Ne Bay Arca Air Quality Management all new materials for inspection.
DimOct? I
❑Yu 'Vol. IJ
than mad NchanN =25505.M33; 2554.1u Chapkffi.95of Nc Wilding
nus I no ly odc,Scctiwu 25505,23333 anJ 7553a.luMcrstaM Juti(Nc Wilding �� /1 , .� r jL U
dos Trot c Ise ly awe¢nano Nat it u my respouihility o notify Js,arupan,of Nc ' I U (�
myuimmntshl,pjust.�e�pria.issaanae nraceni0uk er ar. OS Signature of Applicant j"" Date
Owner or authorissJ agent „e All roof coverings to be lass "B”or better
R Community Development
10300 Torre Avenue
✓" ' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
jj- G ( Med: , c. Ln 0S O O (3
OWNER'S AME: —E i�, K PHONE # Llo S 6 q 3 (a
GENERAL CONTRACTOR: ,— FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the owing 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/Contract gnature Date
Community Development Department
_ s Building Division
> , City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E IST I N O Fax:' (408) 777-3333
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 ob_taini_ng 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$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. - Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding. *
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: ,\ f�z KIi
Job Site Address: a 1 y G I Ck;
Roofing Company Name:
Applicant's Signature: Date: 'i la o S
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
r'
CITY OF CUPERTINO
asmCITY
a ^° z
�CUPEICTIN0 PERMIT APPLICATION FORM
APN # // Date:
3� Z 3U 6 'b.
Building Address: 1
j a I N1 )ta 1 ��
Owner's Name: Phone#:
Tk C\. kAa\� s G() ao�
Contractor: Phone#: License #:
T D »oof,, A ub$ -1y `( 10 c( -- G-TGG z2
Cont t: Phone#: Cupertino Business License #:
� sl e { Iva cc� yog ) gqA 88` -1
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof - . _ ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
X 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: - - -
A.kN„vvle wwc� S��alv�� i rc-. ( acc
Residential Commercial ❑ C u>l�1�
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there areestnct o�ns: LJ
Cost of Pr Ject: Type of Construction ff Occup y” up:
� g50o IL-2 - ri ov r .
Qty. if
A lic e .. 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
e