05110094 (2) CITY OF CUPESION 4,CONTRACTOR INFORMATION
BUILDING DIVISION PERMIT s=*' �
BUILDING ADDRESS: PERMR N0.0 5110 0 94
.10236 PALO VIS
OWNER'S NAME: PERMIT ISSUE DATE
JOHN KLIEN
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUM D MECH
ipo LICENSED CON'RACIOR'S DECLARATION Job DOSCr113t100
V F 1 hcmby affirm Nur I em licensed under provisions of Chapin 9(rnmmcncing
c suj
with
Section
7EM)of Division 3 of Bre Business and Professions Code.and my license is
>> L,foaIo de L 672 REROOF--T/O SHAKE, INSTALL SHINGLES,
i uj- License Class Lle,g
°k-o Dam — Coal.. UNDERLAYMENT #30 OBS, NEW FLASHING
tqquy�
ARCHITECT
S DECLARATIOy
t 2< I undenund to,plain shall be used ss public rectum
)yU
eG Licensed Pmfeeconal
OWNER-BUILDER DECLARATION
ji Z I hereby alum that I sin exempt form the Contraaors License Law for the
-0 o following masa..(Sued.7831.5,Bum.and Prefe ssium Cade:Any city or manly
SSE which mgdrm a permit to mmtrua,alcor,unPmse,dcmolLsh.or repair any strums e
-iyplus,m or its issuance.dsomq.i.the applicant for such Permit tofkasigned summcnt
z that he is licensed pursuant mNepmvisiormofdue Contractor's Lice=Law(Chapuv9 Sq.Ft.Floor Area ValuatfpSB180
Yin-$ (commencing with Section 7000)of Divaion 3 of the Business and Profestions Code)or ���
_ dal he u exempt therefrom and me basis for the alleged eveny vnt tion.AOlodon of
$cation 7031.5 by arty applicant for a permit subjects me applicant to a civil penalty Of APN Number k �[� Occupancy Type
our mom JuTi
n ro hundred dolls.(5500). 3 5 !/�3d �
❑L ss ownm and
pmpr acer m Out ameyees with wages ss dte(Sce.compewness Z
vett do thcwork,and thestmaun,u ml intembed oraRered for Stan($rs.]W4,Business rp�qui ed IIISI OGLIq
and Professions Cede:The Conmaors License Law does rot apply m an ownm of ��-ysq P
progeny who builds orimprowes mercon,and whodeas suchwork himselrar through his (y ��
own employ=.pomkicd .sala Nat such impmmmcnts an,nal intended muttered forIf. /'�� /()y S
howewermet&'.me bsildingwimprommantumld withinarcaldoyear rmmp.forpthe mares,
builder wiB naso me hsmdeo of pmsvmg that k did rot bvid ser impvve rot purpose of
sale.).
D 1.as Owner or the propeny.am exclusively contracting with licensed contractors to
construct the projea(Sec.7044,Business and Profess..Code:)The Countesses U- �aVy
cerise Law dors net apply to an owns of pmpeny'w1h.builds or impmses thereon.aux.
who contras for such pmjeaf with ammOaar(s)limned pursuant to the Contractors
License Law.
❑lanuaeptunder See ,B&PCformisrtsson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby all amber p may of perjury arc of me following dcderatiom:
10 1 ham and will mdnufn a Cerdficateof Cmment m self4mare for WorkcesCompen-
scion,u provided far by Section 3700 or the Labor Code,for the performance of the r
wank for which this permit is issued.
❑1 have and will malum Workers Companudon Insurance,as requin,d by Section
3700 of de L aWr Code,for me penimmma of the work for which this permit u issrcd.
My WmImeCopupe aeon/I sunrcs carrier and Policy number are
Cartier. la�+'e Policy No, �M'ezt4lb
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Tuseethm need not bo complemd if the permit is fora.,hundred dollars(5100)
or las)
I cavity,mat in ase performance of the work for which this permil'm issued.l shill Out
employ any person in any mannerm u On become subject to the Workeri Cmn stmadan
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you mould
bmome subject to the Workers Compensation provisions of the labor Cade,you muss
wJ O forthwith comply with such provisions or oris permit shall be domed evoked.
z' ,
y CONSTRUCTION LENDING AGENCY
[--� Ihe"affirm chat them is a commeann lending agency for Ne performance of
G'> ase.,it fur which Jus Permit 6 issued(See 309T,Civ.C.) .
Uj p Lenders Halt
7 Z L<.den Address
U O 1 certify that 1 ease mad this application and rum mat the above information is
li !' correct.1 agree soue
comply with all city and county ordimrs and som
u laws relating
building construction,and hereby authorizempresenudves of thet city to enter upon the
shove-mendumd progeny for impectioo purposes
F 4 (We)agree to save,indemnify and kap homeless use City of Cupem o against
h Iiabiliacaludgmcnu,eosm and expenses which may in my way scene against sial,City
U Z in consequence of the gran8ng of mu permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued.by: Date
SOURCE REGULATIONS.F
(� Re-roofs
Signame of ApplicanuCch n, Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ute applicant or future building aaupanlstoa or handle havardom material
m defined by the CuportiM Municipal Cade.Chapter 9.12,and da,Health and Safety
otic.Section 35532(,)7
❑Yin ®� All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil hhormom air conmminanu as dcRmed by the Bay Arta Air Quality Management all new materials for inspection.
D n<t1
❑Y
I have mad me hvadtusmaren is regmimm ms under Chnpun6.95 of thc Cs ifur.
.in Hc.lO&Safety COM,Sections 25505,23533 sew 25534.1 understand maifmc building
docs not curmntly have a renans mat it k my responsibility m redly mit Occupant of the
myuiremcnu whkbm be met 'orm maturate of Catifmate of Occup
�h Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner or m nsd agent m" g
Community Development
10300 Torre Avenue
i�amw-
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS:
PERMIT #
/b23Cfl A190o Ucvi Jgcl I zo)�/I/
OWNER'S NAME: o _ - PHONE #
GENERAL CONTRACTOR ,al PL FAX #
I am not using any subcontractors:
Signature D to
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
l/ Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
M10300
Community Development Department
Building Division
City of Cupertino
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 obtaining 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$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4 " per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
/ n
Homeowner's Name: /Q� / /
Job Site Address: !(2 '2-3 6 PaA ( t S r6i Rol,
Roofing Company Name: � j
Applicant's Signature: ev-fvpDate:
Greg Casteel /
Building Official
Revised 11/2/04
Printed on Recycled Paper,
CITY OF CUPERTINO
GGa` REROOF o_wCITT
4 CUPERTINO PERMIT APPLICATION FORM
APN # 36_// � — dS Date:
Building Address:
i0 U `f Rd
Owner's Name: Phone#:
ti ti 9 9 6 3�rvs
Contractor: / / Phone#: License #:
W P/i / L -7 217 2. Sr-
Contact: Phone#: Cupertino Business License#:
Alne 777-5�33/
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ® Asphalt Shingles
IN Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
,0 To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description: `jp y 5777/ /f/vw S6)lk5,$
Residential zl/ Commercial ❑ 11
Fire Zone: Yes ❑ No n2-- Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
g / �t0_e�_
Qty. if
Applicable 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
31