04030131 (2) CITY OF CUPERTINO `.?,M +
PERMIT iM
C�1vT12AC1OR=TtYkOA.TION "n
BUILDING DIVISION ry �u-a,;
BUILDING ADDRESS: PERMIT NO
04030131
•OWNER'S NAME: PERM PISSUEDATE
EL
ONE: SANITARY N0. CONTROL NO.
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
foo LICENSED CONTRACTOR'S DECLARATION O
F I WrOby Airrm Thal I am licensed under provisions of Chapter 9(commencing Job Description
sea with Section 7")of Division Sof the Buineatand Professions Code,and my license is
<E,A in full
fo an p I,_.�3L�;� �iY ..I w. LED
5'�Z LlcenwCl "f°vf'=V Lie.N REROOF rI,V
Da Co. /%
ARCHITECT'S N MAR 2 6 2004
1 understand my plans obeli M Used w
cd public mrds
iC Licensed Professional
OWNER-BUILDER DECLARATION
gs 1 hereby MB-that I am exempt from life Cnnl2Rcbm'a Ueml Las,for In,
§O O following nimon.(Section 1031.5,Business and Proasiuos Cade:Any city or county
20! which requires a Permit m construct,alter.imp now,demolish or repair any structure
1- 12 prior to its issuance.elan require the applicant for such Permit m file a signed statement
F G thatheiallccnmdPunuanthemeprevisionsOftoContrumriLis<nceLaw(Chapter9 Sq. Ft. Floor Area Valuation
of $ (commencing with Section 70(l of Division 3 of the Business and professions Coni)or
that he is exempt themfrmn and the basis for Ne alleged assumption.Any violation of
nowt mom than fivon 7031.5 e�dred dollars($500t for a )"f subjms the applicant a dull penalty of 3 21&413`Uld qr0 0 Occupancy P Y TYPe
❑L As owner of.Ute ryoprny,or 11 employees with wages offered fo samv sole W.Business
will do thewons andtheBm cticeCom is noes Lice de wdo s not apply to an Business
mtl Pmfeadnu Code:The Cs dismaara idwoo Law dors not apply m an owner is Required Inspections
.employ builds orimprovethetam Mtdwhndou aahwork h rmflamd forsahhf,
own employee,provided thhavem improvemanu art net Intended reoffered roe tile,If,
however.Ne building or Improvement is sold within one yeti or completion,the ower
builder will have the burden of proving that he did not Wild or Improve for purpose of
tile.).
❑1,as owner of the properly,am exclusively contracting with licensed conmicwn an
cauauct the pmjem(Sec,7044,Business and Poefesians Cade:)The Cc nuamor's Li.
cense law doss not apply to an owner of progeny who builds ar improve themon,and,
who contracts for aah projects with a contra ler(0 licensed purswnl in the Contractor's
License Law.
❑1 am exempt under Sec. ,B k P C for thio reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
J I hereby affirm under penalty or perjury One or the following dalaradou:
J I have and will maintain n CcNBuln of Consent o selM1lnsum per Worher'sCooper.
ution,As provided for by Section 3700 of the labor Code,for the perrarmena of the,
work for which this permit is issued.
❑I have and will maintain Weakees Compensation losmance,As required by Section
311p of the labor Code.fm the%Aperformance of the woh for which this permit u Issud.
My Worker's C. 11N inaunn a anon mtl policy number are:
Policy No.:
CCERTIFlCATE OFU MPDON WORKERS'
COMPENSATION INS APACE
lase)(IMsaection need not be completed If the Permit is foronc hundred dollars(Hoo)
ear
I unify that in the performance of the work for which Nis permit is issued,l shall not
employ any person in my manner suss In become subject o The Wtolmat Camperaatli,
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,afar making this Ccnificam of Exemption,you should
become subject Me Ne Worker's Compensation previsions of Ne labor Code,you most
.JO forthwith comply with such provisions or this Permit shall be deemed ranked.
'Zr y_ CONMUCfION LENDING AGENCY
'r+ I hereby Kinn that there iaa rouuncurm lioningagcay for the perfmoome,of d
ai rite work for which this permit u issued(Sec.3091,Civ.C.)
LQ Lenders Name
= .z Lender's Address
U C) I certify that 1 have mad this application end slate that the shout information is
IL F cortecL 1 agree On comply with W city and county ordinances and stats laws mhting u
0 building construction.and hereby authorise repteentative of Nis city on enter open thc ��/ �/�\�/hy7(/ ///
ahovementionctl property for iupcction pugases. V��r/�G/a/
ti y (We)agree to tiro,indemnify and kap hamemas the City of Copmoot against
%
liabilities judgments,ru�rasts index s which may in any way accrue apinn said City
in consequcncc of tlteylantin Thi omit.
APPLICAN'� ER D D WILL COMPLY WITH ALL NON-P01 Issued by: Date
SOURCEa LA S. /
tate of Appli / on to, DamRe-roofs
HAZARDOUS MATERIALS DISCLOSURY Type of Roof
Will the Applicant or future building occupant Mom or handle huardous material
ss dcftnodby the Cupenina Municipal Code,Chapter 9.13.and the Health and Safety
rein.Scetlon 35
❑Ye 1YIV5321.)1 `�l��V All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or dcrias which If a roof is iinn�$tallll�y/�,I+without first obtaining an inspection,I agree to remove
it haaardous All cuuminants a&flood by the Bay Ara Air Quality Management all new /a[er at5[pr inspe n.
DIaUlCl1 /
❑Yes
Iharc 5444 humdoui mLyR.1.equitemcnu under Chapter 6.95 of the Califon
ria Health yCod Sado 25505,35533 am1]5534.1 undreamed thMif the building % X
Dees not -nt1Y h a tc that it b my mspouihiliiy m notify the occupant of rite
requi hi must prior .to issoma of a C (sate of Qcupan
/ 2 atureofApplic Date
net oreutho da at D All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS/X� fYtMIT # b y O
OWNER'S NANUiX PHONV*
GENERAL CONTRACT FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinje information:
61 SUBCONTRACTORI 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
2
ner/Contractor Signature Date
j Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
;UP, E' TINO
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: zp i—i /1
Job Site Address: � 7 �.t7lQlZ e�
Roofing Company Name: '' //
#—r
A plicant's Signature: Date: ,' 2,*"'
Gio
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF v f o3 "(3
CUPERTINO PERMIT APPLICATION FORM
APN# 3 Z /' 4-? c, o �_ Date: �56
B ildin Ad r ss
ner's N e: Phnone *1 -
C tr cto Phone#: License#:
5DioW 'fI 7J/5P),
Con Phon Q D/ Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles Jt6_,tt_
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: ❑
J b Desc i tion: I I Z
LA
Resid tal Cdfnmercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are . rictions:
Cost of Project: Typr Const cti n: Occup
CTI , W r—
r
Qty. if
Applieable 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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