04050100 (2) CITY OF CUPERTINO ('+ ■`' '
BUILDING DIVISION PERT u'�`�� T� T" �1�A` y1YlAT1OA� t
,ai 3
BUILDING ADDRESS: SKYLINE ROOFING PERMIT ND04'050100
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
408 353-
ARCHITECIyENGWEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTOR'S DECLARATION O O O
Job Description
1 hemby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section]IXq)ofDlvision 3 of the Business end Prafcsslom Code,and my license is
in ma.0 Jerre . _jam o/q REROOF 000,
-O Z Ucenac Cldi Lk.N 7
�g
Date Cunaamor
AR 1TECT5 DECLTRATION//
I under Y ple� I used u i men�r
Licensed hereby
3 OWNER exempt frDECLARATION
q I hereby
affirm on I am exempt Imre the Contractor's License Law for the /
i p O following mosoa hermit t 7031.5.construct.
Business and Profession Code:Any city or county 0
which requires a Permit to re,flo plea improve.demolih Permit
fie.sig ed swmum
Fib thatpd.he itscensed puts. mqthe reapplicarnor.17 for C.mrsrmiuoear.Low(Chcmem
that licensed Pursuan11.th)of Division
of the eBusimrsnd Professions
(C Code)
Sq.Ft. Floor Area UBhOn
ems$ (cat he is(commencing Sections add the
basis
r b the alleged
eaand Professions Cndc)of ,
.- that he is exempt anmarom and dte anis for be alleged euicant t.Any violation of
not on 7031.5 five
airy applicant for(a 0070th Subjects the applicant m a civil penally of 3 010 0 Occupancy Tf e
not mom than five hunded dollars(5500). P y •7 P
❑I,as owner of the property,or my employees with wages at their sole rompenallon,
will do the work,and the swmure is not intended or offered for sale(Sec.7044,Business
and Professions Coda:The Canoacum's License Law does not apply m an owner of Required Inspections
property who bui Ida.r impmws theroon,and who dor a uch work himself or through his
own employees,provided Nat such impmwmenu are mKintendcA oraQeed for sale.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have Ne burden of proving Nat he did not build Or Improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Catamaran's U. .
care law does not apply to an owner of property who Wilds or improves theeon.and
who contracts for Such projects with a commands)licensed pursuant 70 the Contractor's
License law.
❑I ran exempt under See. ,B k P C for this reason
Owner Doe
WORKER'S COMPENSATION DECLARATION
1 hereby union under penalty of perjury arm of Ne following decimations:
I have and will maintain a Certificate of Consent t0 self-lnaum for WarkmsGompen-
smion,a provided for by gentian J]00 of the Labor Code.for dm peRarmana of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,an retrained by Section
31
00.1 the labor Cada,for tha pmfmmmce of Ne work forwhich this permit is issued.
My Workers Compensation Insunna,cfanicr end P licy number am:
Comer T' �V �D Palle
CE TIFICAR TE OF EXEMPTION FR0 4 WORKERS'
COMPENSATION INSURANCE
(Thlaocclion need notal completed ifthe Permit is resume hundred dollar al(i
or lass.)
1 cenify Not in the performance of the work for which this permit is issued.I shall nut
employ any person in any manner so w to become subject to the Workers'Compenation
Laws of Califomia.Data '
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you most
.J O forthwith comply with such provision or this Kurt shall be deemed revoked.
'Z r.a CONSTRUCTION LENDING AGENCY
[n
4 I hereby affirm that there is a ronsidatinn lending agency for the Performance of
C'
the work far which this permit is issued(Sec.3097.Ci,C.)
IQ lender's Name
gz Lender's Address
V Q 1 codify that I have mad this application and state that the above information is
,r cornet.I agree to comply with all city and county ordinances and sme laws relating to
Q U building convection,and hereby authorise representatives nights city to enter upon the G/ `
G17 liaove-memidgm Progeny for inspection
Purposes.
gy (We)agree la ave,indemnify and keep hmmless the City of Cupertino against
,h incoidculuca or ts,the costsandof this csmit. may in any way eccm)egelnnmid City
C)^ APPLICANT UNDERSTANDStAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 EGU NS� /2
Re-roofs
Signalum of ApplicaUContractor Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will the applicant or future building 0amfulnl store or handle hamdous material
as deflned by the Cupmtino Municipal Code.Chapter 9.12,and the Health and Safety
Agglikodc.SectiYes on 25572(a)? air All.roofs shall be inspected prior to any roofing material being installed.
❑ N
Wig 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
mit handout air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes gD f
I have mad the hamardous materialsmqunammis under Chapter6.95 ofthe Califor-
riaHcol"SuclyCodc,Sermons 25505,25533 and 25534.1undcuund thmif Nc Wilding
docs not cunentI how tent that it is my responsibility to notify the aeupant of the s
quire hien nal et psionuiss cc.1' C ficateof Gccupmcy. Ignature of Applicant Q Date
OAF
Owner or autnonycd agent pate All roof coverings to be Class"B"or better
r
aClOF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
$UPEkTINO
Building De ent
JOB ADDRES N�-)N QD PE IT#
OWNER'S NAME-3;' LL Jh I -g PHONE
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: -��/ 7-O
Signature Date
Please check applicable subcontractors and complete the following information:
63 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
e /Contractor Signature ate •
Community Development Department
Building Division
��j City of Cupertino
4 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
qUPEkTINO
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: CCK- 79' W'--RW/ t✓l 4I' J !�
Roofing Company Name: S
A
pliant'
Signature: Dater fly/
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF C)
CUPEkINO `PERMIT APPLICATION FORM
APN# Z G 6 0 Date:
Building Address: L)G Lc� 12 P 1 �l �•U n �
Owner's Name: Phone
S% LJ H ITC-_
Contractor: Phone#: ��� License#:
S5 KV Lr A.1,E v J 3 � au7?
Contact: e L l Phone#: �lo� Cupertino Business License#:
/�!c/l Lr4 v�/ec�.11
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles a Asphalt Shingles
0Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify) %2
Number of existing coverings I ❑ Provide I.C.B.O.Report#
;d To be Removed ❑ Provide Mfgr. Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑'
. Job Description: T�rouc n.g i i c� �/— lz !''G•/ J��trJ •t o yR c o
Residential Commercial ❑
Fire Zone: Yes ❑ No 0'• Confirmed with Plannin D t. if
there are anrest • ons:
Cost of Project: Type of Constru i Occupancy u .
Y• i
lic le 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