04090177 CITY OF CUPERTINO o 77777777777,
BUILDINGDIVIs1ON PERMIT
BUI�DINGADDRESS: RESPONSIBLE ROOFING INC. PERMIT O04090177
OWNER'S NAME: PERMIT ISSUE DATE
ONE:TERESITA I SANITARY P19. N ROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
E CT 4UMB MECH
uoo LICENSEDCONTRACTOR'S DECLARATION Job Descrip on
(�F I hereby.Mute Nur I am limmed under provisions Of Chapter 9(commencing
Ey with Section 7M) Division Sof NC Businessand Professions Code,and my license is C
^ in ten force and erzLm.a �'z&Y 90 REROOF W/TAR & GRAVEL SCP '?�I 2004
–moo License ass
F Dem Contractor
ARCHITECTS DECLARATION BUILDING U I understand my plans shall Ire usml m public rcenNa B 1 'I e DIN /rlr�
oIn Licensed norhy ionel U L /V—
5 OWNER-BUILDER DECLARATION
1 hereby.(Sinn that 1am 1. .Bump.Item the Con.mmoo License Law for the
p o following reason.(Section](131.5.Busi....nd Professions h.a Any city fir county
which myvims a permit reconstruct,slteG improve,demolish.sc asig ed structure
a Ihior it)t he.lits mucdp.rsantto the thcappnsofant forsuch C.mrarmil mfienseLow(htemcm
ahalhccnein with
pSeouam 70th)provisions3 thehe Busies iLirenmlaons Code)at Sq.FL FIOOT Area ValuaC On
OutM us
Section And dof in batsionr O the Business Professions Code)of
EWE Serio B comp.therefrom and Ne pstr for the cm cd exemption.to Any it Penalty
of
Section than by veairyapplicantforapermitsubjcctaNeapplicantmacrvtlpenaltyof 3. groo Occupancy Type
no.mart than Rw hundred dollen(5500). ,.
❑1,ss owner of and
property,army otimences with wage u Helr sole 0A14,Business
mess
And dntlmst.na.andlh The C.A 13 wee Lim. Laa,itd f not apply to 6C,Noner of Required Inspections
pre,And Professions COde:The Conuacmh ndwho Law duce not apply to an owner is 9 P
own enywho s Idoorimpaves Hereon,andwho Oressuchworkh roffred0lmugh his
awn employee.,provided Hat such improvements Are N year of
or offered foraideto owner.however.He buildings improvement is sold within ore year of completion.He oose of
builder will have Ore bather of paving Nal he did not build or Impmw for purpose Of
sslcJ.
❑1,as Owner of the papeny,am exclusively contracting with licensed contracmra to -
conawct He project(Sec.70".Business and Professions Code:)The C.mmmoes Li.
cense Law does not apply to an awns of papery who builds or improves Hereon.and,
who contracts for such pmjecla with a contractors)licensed pursuant to He COnlOe.ar!
License low.
❑l Am eXCMPL under sec. ,B k P C for this moon
Owner Dale
WORKER'S COMPENSATION DECLARATION
t I hereby afflml under penalty of perjury ON Of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure far WorkerSCumpen-
sation,as pmvidcd for by Section 3700 Of He Labor Cadc,for,the performance of the
weak for which His permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
3700 of the Labor Code,for the performance of He work for which His permit is issued.
My Worke�r's Compensation Insurance carrier and Policy number am: _
Co.ier. 1 /IT/(^ /]...1 Policy No.:713754R12 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection ucad notbccompleteJ If be pcarmi0s fnrone hundred dollars($fall
or less.)
1 certify that in He performance of the work for which Ibis permit is issued,I shall not
employ any person in any manner an es to become subject to the Workers'Compensation
I.of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation previsions of He Labor Code,you must
0 0 f."wiH comply with such provisions or this permil.hall be deemed rew om.
z N CONSTRUCTION LENDING AGENCY
[–i I h.mby AM.Hat Here iiaconstruction lardingagemy for the perf.onam.f
ai> He work for which this permit is issued(Sec.3097,Cih,C.)
0.i Q Lenders Name
z Lender's Address
V 0 1 mnify that 1 have mad thio application and stem Out On.bow infmmatiun is
{Ty F Connect I agree m comply with all city and county ordinatts and sum rela laws ing to
O V building conswnion,and hereby authorise representatives Of His city 1.enter upon He
W above-mentioned property for inspection purposes.
(We)Africa to save,indemnify and keep harmless He City of Cupertino against
N liabilities,ulgmenta,cosh and expeorm which may in any way seem against said City
V"z in consequence of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
�OUR�EGULATI S.
2-1'7 d Re-roofs
Signature of Applicant/Comwelor Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof -
Will He applicant or future building occupant stow or handle hazardous material
az defined M1y the CuNnino Municipal Code,Chapter 9.12,and the Health and Safety
ode,S....2553
tion 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant or fuse building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7dom
mlt hazardous air mAiwAinamu ss deflmd by He Bay Arca Air Quality Management all new materials for inspection.
isrrin?
❑Yes
Ihaveread HehnvaMnuxmauria.2553 And25under C,..d thaddhe Califon
.in Health&Saus!the e,Sections255f15.25533 and 255Ja.I underaund thazifthe Cahr.r. ✓�///
not currently haw a tenam that it i3 my rcaponsibility m maty Ibe mcupanr of the a
cnirememhich must bar met prior u issuance of a Certificate of Occupancy, Signature Of Applicant Date
wauthorized ag— e��d�s Dam All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
t4
' ✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
B I uilding Department
JOB ADDRESS: PERMIT#
10
OWNER'S NAME: Mrs .1 rY2S PHONE # �_ b
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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 2
Septic Tank
Sheet Metal
Sheet Rock
Tile
G�-�L- L(�� q /a
Owner/Contra or Signature Date
c Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
UPEkTINO
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: Mf S I O f Y e s
Job Site Address: iow-n M 1 Vlf 2
Roofing Company Name: V-e5 pnSl 2rY 1 u^ Tv1C
'i
plicant's/Signature: l�z/� Date: q IS
. \�lIr6L11[kX�
Greg feel
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
REROOF q `' 77
CUPER INO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone#:
Contractor: Phone#: License#:
S h RQY6 S O
Contact: Phone#: Cupertino Business License#:
Ea 26710 to s
Type of Roof Covering: .
Existing: Proposed:
Built-Up Roof &-i uilt-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Nu�9ber of existing coverings El Provide I.C.B.O.Report#
L9'To be Removed ❑ Provide Mfgr. Installation Specs.
. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: Tegr R $ ta�se o eXislirg YoU+- /kppiq n¢w -Eqv CAQVe
Vocif
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any res ie ot�lJ
Cost of Project: Type of Construction: Occupancy ou
la °J'10oO �2-YUcs� -
Qty if
An li a 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
i
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