05080134 (2) CITY OF CUPERTINO ^'
BUILDING DIVISION PERMIT .,CUNTI2ACTUIt,.T,�NI„ U,RMATYdlk*
BUILDING ADDRESS: SHELTON ROOFING PERMITNo05080134
1
OWNER'S NAME: PERMIT ISSUE DATE
IRENE HANSEN 1988 LEGHORN ST 08/16/2005
1 NE: SANITARY NO. CONTROL NO.
(650) 961-7699
ARCHITEC IFNIGINEER: BUILDING PERMIT INFO
SiMG ELECT PLUMB MECH
t� t�
30o
LICENSED COKMACTOR'SDECLaRATION Job Description
4 I Wrathy affirm that I am If axed under Pmviaiou of Cha sur 9(commencing
•� with Sation7000)ofDlvlal n3ofthc Bu' eaed Prof is c.mdmy cncels
in full face anea�Zi3� EROOF-T/O WOODSHAKES, RE _ T OSB
i Da�nacGyy Contncmr ADD 40 YR. COMP. SHINGLES
ARCHITECTS DECLARATION1� r 1 understand m plans still h)used u Public meet& 'V`T^
• Licensed Prof usionel ^
OWNEm NuR-BUILDER DECLARATION
ffirm Dl
g I hereby at 1uempt Itee Conacmrs License law far the
0
O O following reason.(Sta1.tion 7(O l.5.Business and improve,
de an Code:My city of county (` C
5$ which its esu a Permit re unwmct,alar.improve,demolish, filo
mains any omcmre n,(J d
that beprior its issuance,p also pursuant
to the the appl(cant for suchthe,Con Permit m fiuse Low(Cha mens ay z
< Nome is licensed purment 7000)a Division
of the, )Bu'se's and
Prorlaw(Chapter Sq.Ft.Floor Area y VI
f S' (' VatU Q
E G
(commencing with Section 70o0)MDivision3nf the Business and Profeuiav Cackles ®
Net he Is exempt therefrom and the basis for the alleged exemption.My violation of l4 F ag- 'tg
Section 7031.5 by any applicant for a permit subjects the applium m a civil penalty of pp N Number OccupagcyzType
out more done five hundred dollars(f3001 3 5 6 20043 . 0 0
❑1,not owner aftlie property,or my employees;with wages as their sole compensation,
will do the work,and the rwcmrt is notimanded oroffered fanale(Sec.7044.Business anRequired Inspections
and Professm"Code:The Contrac70r's License law does amt apply 70 e an owner of q P
propy w ho builds or Improves thereon.and who does such wrck himself or through his
own employees,provided that such improvements are not Intended mortared forsale.If,
hawevcr.the building or Improvement Is sold within can year of completion.the owner-
builder will have dm burden of proving chat W did not build or improve for purpose of
tile.).
❑1,as owner of the Property,am exclusively contracting with licensed contractors in
construct the projal(Sec.7044.Business and Profusion Cade:)The Contracmr's LI-
cu se law dors not apply to an owner of property who builds or improves thereon.and,
who contracts fat such paijecm with a eanuac70Hq licensed pumuam 70 the Convector's .
Llem.Law.
❑Ione exempt under See. .B k PC for this
Owner -_ Data
WORKER'S COMPENSATION DECLARATION - -- -' '- -
1 hereby affirm under Penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent 70 self-Insure for WhrkersCompen-
Wine,se provided for by Section 3700 of dee Labor Code,for the performuce of the
work for which this parnit is issued.
1w and will maintain Worker's Compensation Imunna,as mquired by Sudan
700 of the labor Cade,for the performance of the work for which this permit is isauW.
My Worker mpatsatian Wuruca units and Policy number art:
abler: — �L—& Policy No.S7-- a oIONO—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not b)completed if the Farm,is forma,hundred dollars($100)
or less.)
I unify that in the Performance of the work fu which Nis Permit is issued.I shall not
employ any person In any manners,as to become mbjui to the WorkeaCompenNan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CeniOnte of Exemption,you should
become subjett in the Workers Compensation prevision,of the labor Code,you must
OfaMwiN comply with such Provision or this Permit shall M enteredrevoked.
Z'o CONSTRUCTION LENDING AGENCY
[-c 4 I hereby affirm that there its convection lending for the Performance of
lY 7 tho work for which this Permit a iasued(gee.3097.Civ.C.)
Ga Linda's Name
0.Z Lender'sAddress
U Q I certify that 1 have read this applic"..arW sate thin the above information is
IL r-! chancel.I a&me to comply with all city and county ordinances and state lava relating in
0 building convection,and Wrobysutimdre reprrxntatives of this city to nems upon the
W above-mentioned property for impaction purposes.
4 (We)agree 70 save,indemnify and keep becalm the City of Cupertino agarol
In liabilitiu,judgment,eesu nedexpnrtsu which may in any wayaceme agaiastuid City /
fJ 7
in consequence of the granting of this permit, h]y Issued by: Date
F7 APPLICANT U RSTAND A ILL CO LY WITH ALL N-POINT
SOURCERE TION ,.g.g,Jr//�•I r/
/G/OS Re-roofs
Signature afAppliuHAZARDOr D�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the Cupertino
forum buildingb.Chapter
bubkh Health amaterial
as OCRnd by Om Cupertino Municipal Codc.CMPter 9.13,and the Health and Safety
Id��nOLcu=nLlyhawawninL�ALit4MYMNUibil[tYWflO
de,Section 25532(1)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes []NO
Will 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
It hazardous air comminute u doOnW by the Bay Area Air Quality Management all new materials for inspection.
suict?
❑Yes ❑Na
1haverevel mehuardnusmam[lalunquirenota under Chipmrd.95ofdm Calilm.
Hal"SaWyCodc,Savau 25505,25533 am125534.lunderstanddwifthe building
tify tic oce Ipan,of Nc
quimencou wh Imost be ren pour suancc of cnincam of Oce y Signature of Applicant/ Date
i 6 to
owns m a m gun Dm ., All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OCI OF Fax(408) 777-3333
UPER,TINO
Building De artment
JOB ADDRESS: /l! G1Jn PERMIT
OWNER'S NAME: PHONE # -7 - 5 S Z 9
GENERAL CONTRACTO FAX#
I am not using any subcontractors - a 5
lgnature 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
Septic Tank
Sheet Metal
Sheet Rock
Tile p�
r/Contrac or Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
CUPEI�TINO Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
17 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.
Homeowner's Name: �L�
Job Site Address: �u (o G✓/L�-� .-2
Roofing Company Name:.
Applicant's Signature: Date: �b
Greg Casteel
Building Official
Revised 11/2/04
CITY OF CUPERTINO s�a o 3
I Or '' REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# /
Building Address tQ Yom— _0 IDI
Owner's e: I G� Phone#:
w 257 --5.5-7
— -Contracto .-- — Phone#: License It.
o 9L -
Contact: Phonec- #: Cupertino Business License#:
LIY.A fL O--t- �a
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )4, 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 Com 1 With Cu ertino's Tear Off Policy: , D
Job Descriptio / QS P5 . Q-w 4{o
Residential /l �l Commercial ❑
Fire Zone: Yes ❑ No F1 there
with Planning Det. if
there are any restrictions: LJ
Cost of Project: yo Type of Construction: Occupancy group:
/a G' 9s
Qty. if
A licable Fee ID Fee Description Fee Grou
/ BPERMFEE BIdg Permit Fees BUILDING
BENERGY Ener BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING