03050006 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITRA WF,,URIQMATN''N .
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BUILDING ADDRESS: ROSSETTAS ROOFING PERMIT"°03050006
� 7629 PEACH BTOqqr)M DR
OWNER'S NAME: 401 LINCOLN AVE 'G"SSt n2/2003
KASORA ROBERT
NE: (408) 294-4400 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0, LICENSED CON'TRACTOR'S DECLARATION Job Description
C 1 Mreby affirm Nat 1 sin de
licenced unr provisions of Chapter 9(commcncing t3
U with Sauom'"dof Divislan 3ofNC Busi d Prefessiam Code.and my license
W. infanmina.rd r C ' --Ik,.� geh�y REROOF �11MALe®
,la i License Clus ✓' Lic.N _
Z r o Date Sl 7l Q-3 Contract
ARCHITECI'SDEC ATION +AY 0 2 2003
1 um ray plain hall W recd uhlic rtcnrds_
3, flSCs�4iYi•�VST'. +1r1C�
Licensed Proteai.n 1
OWNER-BUILDER DECLARATION BUILDING
P I herehy affirm Nu 1 am exempt from tLa
he Contractors License w for the
a m o following mason.(Scetion 703 1.5,Business and Pmfcssimu Cole:Any city or county
a S ff which.,.i.a permit to emwrvct,alm,..Impmw,demolish.at rapid,any structuin
prior us its issuance,also m pores the applicant for such permit to file a signed statement
�si< pursuant Nat k is licensed pursuano the provisions of the Contractors Ucemc law(Chapter 9 Sq.Ft. Floor Area $6N)g8tion
9F$ (commencing with Section 7000)of Division 3 of the Business and Profession Cade)or
5 Nat he is exempt therefrom and the hue for the alleged eaempuon.Any violadon of
Section 7031.5 by say applic int for a Permit subjects the applicant to a civil penalty of 3 MN2a"erO 0 Occupancy Type
not mom Nan five hundred dollars(59ID).
❑1,as swot of Ne Property,or an,employees with wages u their aria amp rstdon,
wwdo the wrrk.nd theatrumareenmlmtandeamrartertd rut sire(See.7044.BusinesaJUb - e(1gfired Inspections
and ProCox:The CoThe Conuanora Liame Law dies Inst apply m N owner.f 307 - I NS ULAT IV N p
progeny who builds or improws thereon,and who does such work himself or through his
ownemployces,provided mat such improvements are not Intended oro0ered for sale If. 601 — ROOF TEAR OFF
have.,the Wilding or improwhicat is sold within tam you of completion.the owner
builder will haw the Wrdcn of moving mat he did nm Wild or improve for purpose Of 602 - ROOF PLYWOOD NAIL
aa.). 603 - ROOF BATTENS
1,as owner of the property am exclusively...bacrog wins licenced anmkims to 604 - ROOF IN-PROGRESS
consumer the pmjca(Sec.7044.Business and Professions Code:)The C.nthatao's Li-
cense Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts far such pai wins a anvaetor(s)Banded pursuant in the Contractors
License law.
❑1 am exempt under Sec. .B&P C for this recon
Ow Date
WORKER'S COMPENSATION DECLARATION
I hereby afford under penalty of perjury one of the following dalarariom:
I hoe and will maintain a Certificate of Consent in self-imuin fm Worker's Cori
73700.1'
don,ex provided for by Section 3700 of the Labor Code,for the Performana of the
rk for which mil permit is issued.
I love and will maintain Workers Compensation Imunnce,u inquired by Section
the Labor Code,for do pcdo....of the work fm which this permit is issued.
y Work.rssCCo'tmpe�ns�a'tion Insurance carrier and Policy number am:
a crs.^z Policy :N ` �---rZQ.Q.�_
CERTIFlCA OF EXEMPf1ONFROW2,011KERS'
COMPENSATION INSU NCE
(This section need nothccomplered if the permit is formic hundred dollars($100)
or to..)
1 codify mat in the Performance of the work for which this Permit a issued.I shall nm
employ any person in any manner an a in become subject to the Workeri Campensauon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifica¢of Exemptionyou should
become subject in the Worker's Compensation provisions of the Labor Code,you must
.JO funhwith comply with such provisions or this permit shall W deemed revoked. -
Z to CONSTRUCTION LENDING AGENCY
[r Ihereby affrm[hat inert is a comrmcunn handing agency for the performam:cur
tY> the weak for which the Permit is issand(sec.3W7.Co,C.)
u C] Lender Name (^
LL Lender's Agrees V
U Q 1 certify inn I have rad this application and sore me Oc&how information e
F corintt I agree m comply with ill city and county ordinances and sea laws misting to
r upon
0 C)
building agree to and hereby indbmnify and
e representatives a this OfCu enaen ago the
W sbovcmeadhar Property for inspection purposes
(We)agree m sive,indemnify and kttp may
in a the City o Cupenittl against
rag liabilities,judgments.costs and expenses which may in any way a<crve ageinnsild City
U Z in corurymnce of fee granting of this Permit Date
APPLICANT of
AND WILL COMPLY WITH ALL NON PGINT Issued by:
SOURCE REEQ�ULAGONS.
�rkc � �LP�Gid �a1r�'3 Re-roofs
gnuom of AndicanUCon me for Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant orf num building accupi m swm or bundle hvardous material
as defined by the Cupertino Municipal Code.CMPar 9.12,ad the Health and Safety
Code.Sadao 255320)? All roofs shall be inspected prior to any roofing material being installed.
0 Yea V.
If a roof is installed without first obtaining an inspection,I agree to remove
will the app icam or future Wilding=upon[use equipmem.r devices which
mit harardnus air contaminants as defincol by da Bay Area Air Quality Management all new materials for inspection.
District?
❑Ya XNo
I have mad the harardnus materials requirements unxrCMparti.95 of the Califor-
nuHalm&SafetyCode.Scetiom25505,25533 am125534.1 unxrstuk thatifthe Wilding
dem not currently haw a avant Nat it is my u samohnlity to ratify tic occupant of the
requirements which must be met pdorwissuamc oil Ccnificaaor Occupancy. Signature Of Applicant Date
c'1aI All roof coverings to be Class or better
0 runmhorimd agent Date
Community Development Department
Building Division
a e City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
Fax: (408)777-3333
C U PE kT 1 N
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 Y4" 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: RC)QeT-A- QQA_ SOr-Q
Job Site Address: 1 a al peace Bkcc5sDrr. 1!
Roofing Company Name:
A plicant'sSSignature: MaAy__ OAn Date: '61Qb3
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO S�
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN # Date: cS 1 aI l7 3
Building AddreW.
�l 1F�1 17r .
Owner's Name: Phone #:
Sora 11D �1910 -
Cont,actor: Phone #: License #:
e�u� Pr P s Ll 9ti-L40o -11-13 LD
Contact: Ph9ne #: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
A Asphalt Shingles ,p Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings cam_ ❑ Provide I.C.B.O.Report# 65tw t7 tp?.
3- To be Removed ❑ Provide Mfgr. Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: rax-nou-.o- e Ficb-vir,5 t-Do-, , i Certr,;�d tr, .
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning-Rept. if
there are an restri tons:
Cost of P ject: Type of Construction: Occupancy grou
Qty. if
A li abl Fee ID Fee Description Fee Group
BPERMFEE Bld g Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
•
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