03100027 (2) 'CITY OF CUPERTINO ��--vs �T` aA7777;777-77-7777T777� a 1�7 n I��
BUILDING DIVISION PERMIT VC1N'TRACTOR INF.ORMA'�ION ,
F v :
BUILDINGADDRESS: "CONDITIONED AIR PERMIT NO.03100027
FAA PEACH RIQ22C)m DR
OWNER'S NAME: 164B GILMAN AVE PERMIT ISSUE DATE
NE: (408) 374-6311 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'SDECLARATION JobDescri tion
i C I hereby affirm Nal I am licensed code,provisions of Chapter 9(commencing P
iib with Section]IXNq of Uivixion7of NC Businc. dPmfcssin sc dmy lice is
=y in full farce andcliti.�V ' RNACE & ASC �'����®
t v g License Class�/� a
F Dam r+! No—I,. or
Qq ARCHITECTS DECLARATION
i d< 1 understand my plans shall be used as public records
U MAR 2 6 2004
ay
°u0� Licensed Professional
OWNER-BUILDER DECLARATION 11
1N�
a S I herchy affirm Nal I am exempt from the Contractor's License Law for the �U'�®'p1
p O following reason.(Section 71131.5,Business and Professions Code:Any city tor county
e m which requires a permit to construct,alter,improve,demolish,or repair any structure
Uzi prior In its issuance,also requires the applicant for such permit to file a signed statement
a that he is licensed pursuant mthe provisions oftheContractor'sLicense Low(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Cooc)or
Net he is exempt Ncrefmm and the hasis for the alleged exemption.Any violation of 36611128 . 00
Section]031.5 by any xpplicent for a permit subjects Ne applicant to a civil panalty of APN Number Occupancy Type
not more Nan Eve hundred doll..(5500).
❑ 1,m owner of the propeny,or my employees with wages as their sole compensation, A7i�irp�7p��Tf((���
will do the work,and Ne structure is nut intended or offered for sale(Sec.7094,Business — H If Lgtl3iee'iD9C[IODS
and Poorest ions Code:The Comnctor's License Law does not apply to an owner of ��6"i`
property who builds orimpravcs thereon,and who doessuch wrrkhimself or through his 303 - ROUGH M CHANT AL
own employees,provided that such improvements are not intended.,offered forsale.If. 304 — ROUGH ELECTRICAL
however,to building or improvement is sold within one year of completion.Ne owner-
builderwillhevetheburdenof proving Nat he did not build or improve for purpose of 505 - FINAL ELECTRICAL
sale.).
❑Las owner ofNe prnpeny,am exclusively contracting with licensed contractorsto 507 - FINAL PLUMBING
conswct the project(Sao.7346,Business and Professions Code:)The Contractor's Li. 508 FINAL MECHANICAL
rue Law docs not apply to an owner of property who Wilds or improves Neroon,and
who contracts for such projecm with a contractor(s)licensed pursuant o the Contractor's
License Law.
❑1 am exempt under Sec. B$P C for thiucsson
DWner Dam
WORKER'S COMPENSATION DECLARATION
I hereby ant under penalty of perjury anti of the fallowing declarations:
I have and will maintain a Candidate of Cm.cnl to self-insure for Worker's Compen-
smion,ssprovided for by Section J]00 of the labor Code,for the performance of the
work for which this permit is issued,
have and will maintain Worker's Compensation Insurance,ss required by Senion
W of the Labor Cod.,for Ne p.tf nnuoicc of Be work for which this permit is issued.
My
Worker's Compensation Insurance carrier and Policy number am:
Canier2- _UA.a.CA Cl/W�a'x Policy No.37�-�77�.5_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction need not W completed if the Permit is furore hundred dollars(SINT
or lam.)
1 certify Out in thc p.rformanec of the work for which this permit is issued,)shall not
employ any person in any manner so ss to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicam of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code,you must ,
�O forthwith comply with such provisions or this permit shall be deemed revoked. -
Z� CONSTRUCTION LENDING AGENCY
I herchy affirm that there is a construction lending agency for the performance of
Y,> had work fur which this permit is issued(Sec.3097.Civ.C.)
QLender's Name
z Lender's Address
;)0 1 certify that 1 have read this application and sum that the above information is
y F correct.I agree to comply wit all city and county ordinances and sme laws relating to
DU building construction,and hereby authorise representatives of this city to enter Upon[he
W .hove-mentioned property for inspeeunn purposes.
(W.)agree to save,indemnify and keep harmless the City of Cupertino against
fa/1 liabilities,judgments, sts and expenses which may in any wayaccm.against said City
J 7 in conuquena of Noting of is
t� APPLICA T RSTA LL CO Y WITH ALL NON-POINT Issued by: Dale
�OL
SOURCE R
?!;A4
6/ f�
tf Re-roofs.
Signature of ApplicariVCentractur Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wilby t applicant o uwrc ipal o Occupant,Chpstorco,handle Health us and material
az defined by the Cupertino unicipel Code,Chapter 9.12,and the Health and Safety �
ode,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.[]Yea No
Will the applicant or fu re building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air conuminan m darned by the Bay Area Air Quality Management all new materials for inspection.
,strict?
❑Yes ❑
I have mad the harardnus aerials requirements under Chapmr5.95 of the Califo>
niaNwldt A Sadfietycilde,Sections 25505X533 and 25534.1 undersNnd Nmif the building
deer not cuocnu tenant, m i repond,1ity W redly the nocupant of the
rcyuiremwu Noxi to" aneor:�6mlicatiofOcdupari Signature of Applicant Date
tOf=l�
Owner m authorised.gem All roof coverings to be Class "B" or better
Dam
10!02/2003 19: 22 5105303282 LEGALITIES INK PAGE 02
;04d1h Bay Permit Service
SON
CITY OF CUPERTINOiCa� /ley,CA 94646.
FURNACE/AC
❑7Y OF
UPEkTINO PE"RMIT APPLICATION FORM s-to
APN # ( 2 Date: /
Building Addres
Owner's Name � ` � Phone#: ��6 '�,3
Lo
Contract Phone: License#
dl
-2 Z zO `A `/S /6
-
Contact: — Phone Cupertino Business Li ense #:
¢1 S — Z z3 3
Building Permit Info:
Bldg, ❑ Elects Plumb Meth
Job Description: P-C G`o ' 7, o o o 9 P Lk
Residential Commercial ❑
For Residential Installations
Attic I" floor 2"` floor
Where to min set back require entjRf I
or Commercial Installations:i
Replacement same weight. Q )Additional weight (structural calcs) ❑
Structural Calculations required 0r new installation ❑
New installation Planning An .rc'�val Required
Cost of Pro'ect: i' Tvpe of Construction: Occupancy group:
'? t7o
Strapped LJ On Platforrno. Bonded 0 Sq.Ft. Floor Area:
i''I
New Location' ❑ Replaecmant
Qty. if 0 T
A licable FeeID. Fee Description Fee Group
BENERGY ' Energy BUILDING
BRENIFURN ._ Relocation of Furnace MECHANICAL
BREMACO R w A/C Unit > 10,000 cfm MECHANICAL
1 BREMAIRHA V ALC Units <= 10, 000 cfm MECHANICAL
BREMRECEP v Rec tl, Switch & Outlets ELECTRICAL
BSEISMTCRE: Seismic Fee Res BUILDING
I EPERMITF Elec Permit Issuance ELECTRICAL
MPERMITFE Mech Permit Issuance MECHANICAL
1 PPERMITFEE' PlumbingPermit Issue PLUMBING
BPERMFEE BldE Permit Fees BUILDING
BPL CHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
' CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFfORMAT7O'
BUILDING ADDRESS: WOODS ROOFING PERMIT NO.03100127
OWNER'S NAME: 2179 STONE AVENUE STE 22 PERMIT ISSUE DATE
NE' (831) 637-5576 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG I 0 f PLUMB MECH
0 0 0
000 LICENSED CONTRACTOR'S I DECLARATION' IOb Description
I u C 1 hereby affirm met 1 am licensed under provisions of Chapter 9(commencing P
c with Section 7000)of Division 3 of NC BusincasendP (,scions Ccde,and liccnkis
„ in full forceandeffe3 ROOF
o�'? Licenu Clad Lic, a
it Dau /s I Curer
ARCHITECTSDECLARATION
i�a 1 undcrsmnJ my plans shall he..ds poetic records
O
' vI
LLy Licensed Professional
OWNER-BUILDER DECLARATION
ComoION
n E I hereby affirm Nal 1 1. exempt from Ne Contractor'¢License Law for the
p O following mason.Permit
t ]I13L5,Business and Pmfc.iimi Code:Any airy or county
$ which its issuance,
n permit re construct,ehda improve,h perm it to
nr a pair any structure
atement
?ry Frimmits censedpurmanequiree the
evisiosO for such Pdtor's iccn Law(Chapter
yinthat henwJpu.mmeu0)ofDivision3ohcCom.aasandProflaonsCodmr9 Sq.Ft.Floor Area Valuation
N th(commencingthe
xemith Section7000)and of basison3oftheegeduseand Professions CaAc7 carr
�
that he u exempt mcmfrom and to baso for me alleged exemption.Any violation of 36611147 . 00
Section 7031.5 by any applicant for a permit subjects me applicanuo a civil penalty of APN Number Occupancy Type
not more man five hundred doll..($501).
1,as owner of the property,or my employee&with wages Is their sole compensation,
will do to work.and to structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Convector'&License Law tone not apply to an owner of Required Inspections
property who builds viimproves meimpr improvements
who does such work himself or through his
own employees,providrt inovahimprovementrte not ear ofdsmeared frosele owner-
builder
Use building orimprovementiehaltwithinoneyear of completion,pu oose of
builder will have me burden of proving mel he did not build or improve for purpose of /
01, -
❑1,as owner of me Sec.70y,am exclusively contracting ng wire licensed contractors to
construct the project(Sec.]044,Business and property
who
Cate:)The Convenor]n. nd V
Li-
cense Law does not such ply m an owner ont ropeny who sed p m improve Connector. -
who convect for such projects wire a cnmranor(s)licensed pursuem to me ConvectoYa
LicenseLaw.
❑1 am exempt under Stt. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under porosity of Perjury one of the fallowing declarations:
1 have and will maintain a Certificate of Consent to self-insure for WorkcesComfort.
mmin,m provided for by Section 3700 of the labor Code,for to performance of the
work for which Nis permit is iumcd.
have and will maintain Worker's Compensation Insurance,m required by Section
OR of to Labor Code,for the perfarm inea of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier, C /�-- Policy No.:sak5—O3�l'fI
j`-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if me permit is fnronc hundred dollars(SIM)
or less.)
1 Comfy mal in the performance of the work for which This permit is issued,I shall not '
employ any peon in any manner an a at become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:if,after making mix Ceniricate of Exemption,you should
become subject to the Workeri Campenmtian provisions of the Lahm Cndc,you most
7Z forthwith comply with such provisions or this Fermi i shall be deemed revoked.
� .~NrCONSTRUCTION LENDING AGENCY
I hereby aRrm that there is a construction lending agency for me Performance of
the work for which this permit is issued(See.3097,CO,.C.)
A Lender's Name
z Lender's Address
;)Q I certify her 1 have mad mis application and nam that me above information miis
y H building I agree to comply with all city and county onlinances and Cute laws miming
to
V building construction,andfor
edicmPM.m¢enmtives of mi¢city wcnmrupon the
N W aM1ovc-(We)a agree
propene for emnify an keep ho
(We)egme la cove,indemnify and kith hay in an the City of Cupcnst against
tie intimsesjutgm f to costs and expensesipermit. may in any way accost against mid City LC///
:)7 A APPLICANT
of lhERSTA gof Nis Fcrmil.
'^• APPLICANT U ERSTAND A ILL ALL NON-POINT Issued by: Da
SOURCE RE ATIO
ro/b`4� Re-roofs
Signew.of Ap,11cm9Cmu.Lp1 Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future building oecupam score or handle harardous material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Healm and Safety
Code,Samoa 25532(a)+❑Yes No
`J All roofs shall be inspected prior to any roofing material being installed.
�S
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
it hazardous air com.minant m defined by the Bay Area Air Quality Management all new materials for inspection.
Dixvlct?
❑Yes No (,/J/? ' O7.yg/JynWn '`•�.� /,y ./y,q
noIt have
V'urtenlmail
the
a0sSNnials requirements under ChePcr6p.95ofmc Collins,aol
. y33 nd2553lily1 anncaund mu if e
uxi: Eisx re'loom4dfy Ih0 necu NtiliaHcalmA,safny Sections 25505huljflimng
does p.4mm-twhirmuct=Cttit sne CcmrcAofGet.
r��C
Signature of ApPlicant Date
Owner maamori.d agent Date All roof coverings to be Class "B" or better
Community Development Department
n . Building Division
{v' City of Cupertino
10300 Torre Avenue
4CITY OF Telephone: (408)777-3228
UPEkTINO 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 LC.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: EGL4_--r ( (�
Job Site Address: 7 6.5 k ��'/ 0,� . Y 0 Lc J�L
Roofing Company Name: L4)&7)4' .5 /G�' 4-.
Applicant's Signature: Date:
GregO\�ll4Sl/0(XX1
teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO 3 Zr7
00--
REROOF v
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: 6 (os n s
Owner's Name::-c Phone#:
1 25 5 -2-vo s
Contractor: , Pho e#: License#:
G(J S o� 6 �/0 OeO3 3 2S/3
Contact: Phone#: Cupertino Business License#:
en �� 2—uf/0
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ 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 Tear Off Policy:
Job Descri tion:
� 0 Vd
Residential Commercial F-1
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
)4/L/(,
6U
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
23Sv � r7
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