00040084 (2) Z7b bO
PERMI
APPLICATION FOR CITY OF CUPERTINO NUMBE
_ -m = INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (4 >777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
�x 180 DAYSSFROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�xf• y'� Y�CAx�r- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
-, NO ❑ Initial I.C.B.O.N
ADDRESS J- EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS v'
PHONE
CONTRACTOR'S
• TO BE REMOVED TO BE RETAINED
NAME
ADDRESS I TY OOF COVERING
CITY&ZIP EXISTING
PHONE &:Sb 26016.:/2� BUILT-UP ROOF /2
NUMBER L2.3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my,license is In full force andYA
effect
License
WOOD SHINGLES
Licen
se ClCI s Lic.Number
OTHER(SPECIFY) L
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED \
I hereby affirm that I am exempt from the Contractor's License Law for theloli.wi g reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve.demolish,of repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provislons
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
E]1,as owner of the property,or my employees with wages as their sola compensation,will do (/ 1n
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- I
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ElImproves thereon,and who does such work himself or through his own employees,provided Nat
such improvements are not intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct \
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to Na Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I herea affirm under penalty of perjury one of the following declaration:
ave and will maintain a Certificate of Consent to salbinsure for Worker's Compensation, Building
as provided for by Section 3700 o1 the Labor Cotle,for the performance of the work for which this
permit is Issued. ^�
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
0� .N~
EJ the Labor Code,for the performance of the work for which this permit Is issued.My Worker's -/ f
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. Pi AUTHORIZA310N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.C]
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All r00 allfili be ingrecred prior to any roofing material being
fornia. inst ed. If a roof is installed without first obtaining an
Date Applicant ins ection,I agree to remove all new materials for inspection.
subjectm@e WorkerTO s Compensation proviANT: if,after slonts ofeheflcate Lebo�Cotla,Exemption,
lu mlulorthwl�hbecome comply A plicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked. source regulations.
I certify that I have read this application and stat.that the above information Is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnlfy and keep harmless the City of Cupertino against liabilities,
judgments,vests and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the gmnhng of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI r NO.
/ OWNERS NA G?8330 REGNART(BEHIND) APPLICTION00i'M005
/ PHONE. SANI'T'ARY N(L10� GRLll+NIJ.
SAN JOSE WATER WORKS lYJ WG/O;fyILIVJL
M p zO ARCHI'lf I/E GU EIi II' BUILDING PERMITINI'O
m_ BLDG M
I.1.17C'1' PLUMB SCI{
U
Lay
yLICENSED CONDECLARATION Job Description
C z m hmeny allimh thw TRACTOR'S 1 am licensed nolo,provisions of C'hua,,9(1 an"tmng
f"y:Lean with Sminn 7fffoIIl(((fyyyy))))h of +io '.1r a 3 he nm
I{ndpas l Pmfnsions CMe,and my neen.e
6 Y Iain Gill Fo f
i C ` Lic,nsc C "ZLot.al
C
to nntrnnnr
- l'reCl-s DecLnRnru)N 100 AMP PANEL
C O 5 I under, id my plans shall he used as public records
to
zn¢5
W p C Llccn,ed Prore,,iantl
OWNER-13
UILO[R DECLARA'T'ION
a u 1 hereby anion nun 1 Int exempt li'onh the Cnmraaor'%License law for the
t—z>• follow ing maws smarm 7031.5,Business and Professions Cole:Any city or county
� e wM1tAy pI it to t t It p dronolfi,h.or mlpa, y ortrone
c3. prior[it itsLo q the ppl ant,lior,mchpe t V,file n limd,odeno,ol
that he is licen,etlp :vat to the p a ofthControcioesl ce«la (Chper9 Sq. Ft. Floor Area iti.Lualion
(eon 6 ll S ct pfNllfl I
Drvi,ka,3 of 0II ration" I P I ' 'Cod')
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 70315 by any uppllcum for u permit nuh',a the applicant to a civil penalty
of not mom than rvchomdmldmlm,(5500), APN Number Occupancyif
❑1.a.owner of the popery,to.11,emtployeca with wane'nx their sole"nole"nlion,
will do the work.and the swcture is not intended or offered fur sale(Sec.NW.
Buninuas DIN Prol'csainn,Chalo:The Comnr7or'a License Law does not apply In an fired Inspections
owner of property Who hand,or lnhprovcs thereon,and who doe,such work noosell 3E,E39005. t
or thought his own cmpinyces,provided that such improvements am not intended or
oB'emd to,sale.IL however.the building n,inomi,emc o In sold widJn one yem of
completion,the ownc,.huJder will has,the bardrnofpmving that rte did not build or 304 — ROUGH ELECTRICAL -
mptoc For i miaow of xul,J.
❑Lax Ownerof the property.am exclusively contracting with licensed contractors to 501.
— FINAL ELECTRICAL ENERGY
construct the project(See.AP4.Business and P.oIt,.ion.Codc)'n,e C„mracmrs 505 — FINAL ELECTRICAL
License Law docs not apply ah an owner or proper)who builds or improves theme.
and no ,ontmeta it,such pnjced who a eommemr(a)licensed pursuant to he
Contractors License I.aw.
Cl 1 am exennpt under Sec. .B&1'C for this maven
Owner.Date
WORKER'S COMI'ENSA'I'ION DECLARATION ,
1 hereby affvm under penalty ofperjury nor mf rhe following declarations:
❑ 1 have and will maintain a Cenifi,ate of Consent to self-in um lin Worker's
Cnnn,rn,afo., as provided for by Section 37W of the Labor Calc, for the
per6mtounce.Pili,work fur,hid,this pursuit is..aucd. _
❑I hav�Ql�and 'it” C nt i'n In'nunnce. I,mphal by Seennn
37N)ofthe ounce of the work for which flax lennit is
issued.M ' nsumnce carrier and Policy nw/doer arch:
Carlin : SAiry Na.:F-c .3 _617-7--
I
(p /� .
J017E%CMITI(INFROMWORKERSPENSATR&Y N. TVZIN vq -TL'�1
('Phis scetiun need not be completed iiff the perait Is t'or nnc hundred dollars
With sir less.)
1 eeoify that in the performance of the work for which this permit is issued.1
shall not employ any person in any manner so as to become subjmt to the Workers'
Compensation Lawa of calikonia.Date
Applicant
ND'I'I ETOAPPLICANT:it,altermaking this Crmfente of Exnnption,you should
becomsubject e subjeco the Worker's Compenealmri Il the Labor Cale,you must
Q O forthwith comply with such oto isions or this permit shall be,deemed rooked.
^F ^
CONS'll(ON LENDING AGENCY
I hereny affirm mut them inn conamcaan lending agency Sir the performance
W of the work for which this permit is issued(See.3097.Civ.C.1
Q Lender's Name
5 z Lsndcr's Address
C.7 C I e,n,fy that I has„cad this nppllcutlon:ted state that the dons,inlb,mation is
tz correct,I agree it,comply with all city and county ordinances and state laws relating
Q (, to building commdinn,and hereby an damose,eme%entatives ofrhis cipymemer upon
It,al ovo-menllmnW propmy he Insp,oti pm,ow,
t-„ A. (We).greem Wive,indemnify and keep bene,, he City of Cotenino against
V1 linithocs,judgmcnta,costs tuna expenses which may in any way aceme against said
V z City in consrqucocc of the granong of this pcnuit O 1�)
APPLICANT UNDERSTANDS AND WILL 7MP1 nALL NQN-PPP���INT Issued by: 1-� ) Date
SOURCE REGULATIONS. am U— y' /
' nnwre of ApplicIIA C te Re-roofs
HALANUOUSM :<IALS , ameASUHE
'u me applicant a stare n, mg«,ulnae arm or lumlle haraNdus material Type of Roof
as donned by the Capanino Municipal Coda Chapter 9,I2,nnJ the Health and Safety
Code.Smtion 255320)7
❑Yen 0N All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future building srcumm use emipnent or de%ices which If a roof is installed without first obtaining an inspection, I agree to remove
emit h:rrurdom air eommn....on,a'defined by the Boy Arca Air Dr city hlxnngnncnt
Mono? all new materials for inspection. Applicant understands and will comply with
El yes Cl No all non-point source regulations.
I have mad the bend...materials requirements under Chapter 6,95 of the
California Hoath&Sufety Curio.Scetiuns'+55(R,25533; 125534.I unJc,aaoal that
ifdancildingdoesmncu,rentyhae iu t,thatit ie myresporoibility to not lfy the
cupea of the re4uircmm�rc whic ten Prior to iouame of a Cedifeme of
Occupancy' Signature of Applicant Date
All roof coverings to be Class•B+• or better
OFFICE