03080156 (2) /J
TY OF CUPEWHNO
BUILDING DIVISION PERMITriCONTRACTORINFORMATIO..bN�".
RMA I
DING ADDRESS: COSMOS ROOFING PERMITN0030a0156
NGG DR
ER'SNAME: 1901 OLD MIDDLEFIELD WY PERMIT ISSUE DATENE: SANITARY O. CONTROL NO.
(415) 493-6373
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MIMI
0 0 0 0
+Gp LICENSED CONIBACmR'S DECLARATION
U I bercby affirm Nat 1 am licensed under provisions of Chapter 9(commencing Job Description
wim Se,titm 7000).r Di r.km3of tiro Bp&mCb.md P in Cod a enae is
E in full force and ci t.''�C�
jam LicenugClmq�`_ 1Lic.x �'�F
;w Dam -/ V/G] Cumren r — �INAE�
¢¢ �— ARCHITLLTg DECLARATION A
Ia Iunderstand Cry plans shall Wused.,public recmd. L.
6
.LL Licensed Professional
O OWNER-BUILDER DECLARATION SEP 1 ('2003
X I hereby affirm that I am exempt from the Contractor's License Law lot rhe
00 following reason.(Section 7031.5,Business and Profox ions Cale:Any city or county
5$ which myuires a permit m ennswct,alux.improve,demolish,or repair any stmcmrt Ifts 28.1,
_Z< prior i its issuantt.slw requirutheapplieam I...Ch peimitm fileasignedsWmmem
that he is licensed pmsuanuo the provisions of the Comncmr's License faw(Chap¢r 9 Sq. Ft. Floor Area 1~11JAIVU Valuat on
0 (commencing with Section 7070)of Division 3 of the B usirom and Professions Cale)or
Cost he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7091.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN.Number Occupancy Type..
not mum roan five hundred dolhn(g500). -- -- ----
❑I,a owner of the pmpeny,or my employee.with wages as their sole compensation,
will do Coe work.and me swcmm is not intended or offered for sale(Sec.7044,Business 305 - FRAME
and Professions Code:The Currecies's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himxlfomhrough his 307 - INSULATION
own employees,provided that such improvements an not intended oroffaed(orale.If. 601 - ROOF TEAR OFF
however,the building or improvement is sold within one year of completion,Coe owner
builder will have the burden of proving that he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
sale.).
I,.,owner of the property.am esclursonly contracting with Bared contractors to 603 - ROOF BATTENS _
Conover Urn pmjcct(Sec.7Us<,Business and Profudmu Code:)The Conuucari Li. 604 - ROOF.. IN-PROGRESS
cense law docs not apply to an owner of property who Wilds or improve mcmon.and, _
who comucu for...h projects with a contractor(&)licensed pursuanuo the Contractor's
License Law. ,
I an exempt under Sec. ,B&P C for this mason
nor Data
WORKER'S COMPENSATION DECLARATION - .. ._..
I hereby affirm under penalty of perjury oro of the fallowing declarations: ...
I have and will main W n a Cenifrcate of Comm to xif--insure for Worker's Compcm
sation,as provided for by Section 3700 of Ne labor Code,for the pelf....of the -
work for which Nis permit is issued.
have and will maintain Worker's Compensation In...so mquimd by Section
of the Tabor Code,for the performance of me work for which this permit is issued.
y Worke�r'yvf�rmagg��s�a(yLp In race c C,and Policy n�umbbeer/pm:
Carver. b// nom// Policy No,: ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flTlamction need not hocomplaed lime permit is forone hundreddolt..($]Q))
or less.)
1 certify that in the performaoec of the work for which Nis permit is iuved.I shall not
employ any person in any manner so as w become subject to me Workeri Compensation
law.of Celiforom Dao;
Applicant
NOTICE TO APPLICANT:Ir.after making Nis Certificam of Exemption,you should
become subject to me Worker's Compensation provisions of me labor Code,you most
,Z fonhwi to comply with such provisions or this Permit hall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affrm mat mere is constmction lending agency to the performance of
x > me work for which this permit is issued(Sec.3097,Civ,C.)
31 0 Undeh Name
z Lender'.Address
I certify that 1 have mad this application and sum that me above information is
1 F moaner.I agree to comply wild all city and county ordinances and state laws miming to
�YJ building commuction,and hereby summits,repreanutive of this city to enter upon the
G above-mentioned propeny for maMcdon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r N liabilitle.,judgmenta.eosu and aperoswhich may in any way accrve against said City a
..)z in comqucne. the gzonfn a" 'mets /
^ APPLICA DFJt T WILL MPLYIVITH ALL N POINT Issued by: Date
SOU E �2 2
Re-roofs
Signature of Applicaa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wit]the applicant or future Wilding..Occupant ptstoreor handle Health amamdal
defined by the Cupenina Municipal Lodc.Chapter 9.12,end the Health and safety
de.Seeded 25532(a)? All roofs shall be inspected prior to any roofing material being installed,
❑Ya �No
Will me applic&AL err future Wilding occupant use equipment or devices which .If a roof is installed without first obtaining an inspection,I agree to remove
itharasdne air contaminants.,defirsed by me Bay Area Air Quality Management all new materials for Inspection.
0 yea
I have mad the havadtws materials requimmcnts under Chapter 6.95 prim Califon a
nias noth&ently hawaScNonshat it5.255Aond2553a,1 un dcrsunte up Wilding d
dies not curendy haw a tenant.met it is my msponsihility m nndl'yy the upwt f me
m uircmcntswN pat hme o uame.f edifier a Signature of Applicant Date
L�03
Ownet pe It Date Date All roof coverings to be Class "B"or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
' Telephone: (408)777-3228
CITY OF
U P E RT 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 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 ab__o��ve stated policy on re-roofing.
Homeowner's Name: a-^o
Job Site Address: /06/
Roofing Company Name:
� n
A phcanYDate:
Greg eel
Building Official
Revised 1/30/03.
Printed on Recycled Paper
CITY OF CUPERTINO o /-5
REROOF v
CUPERTINO PERMIT APPLICATION FORM
APN# , 7 Date: G/o3
Building Addres ✓ UA.A�
Owner' Name: ' Phgne#: S7-7.53
tractor: Pone#: License#:
to469-76.3 ?�SS/.el/
Contact: n Phone0..r- Cupertino Businesslicense#:
dr .¢_ !
Type of Roof Covering:
Existing: Proposed:
* Built-Up Roof �C Built-Up roof
El 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 Te Off Policy:
Job Description:T e "4
Q a0� X (/ /<O Lz/ _ O
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with P t. if
there are any re icons:
Cost of Pror u
•ect: Type of Con cti Occupancy gp•
Si�I • aD
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE BIPermit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING