03120095 (2) CITY OF CUPERTINO o ` a '
BUILDING DIVISION PERMIT Cf)ATRACTbR INP( RMAT, ,
auILDING ADDRESS: DAN ELLIOTT I S ROOFING CO PERMIT NOO 3120095
OWNER'S NAME: FERMff'f55UEDATE
ONE: SANITARY N0. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby afrrm Out 1 am I camead under provisions of Chapter 9(commencing P
with Satin.7")of Division 3 of NC FORMOm Mal Professions COde,and my license is '
4�cimmurareeande�it. ace « ! 3 REROOF ��R■
Daenac Claz IS .�1A,'„
nFp Dam f4 -/L. — Cuntracmr ED
ARCHITECTS DEC RATION
I understand my plans shall be uacd as public records JAN
0 7 2004
;off Licensed Pndcssional -
g g OWNER-BUILDER DECLARATION
4 a f 1 hereby affirm that 1 am exempt from Ne Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county BUILDING
1$� which requires a permit in construct,alter,improve,demolish,ter repair any structure
Zia` prior to its issuance,also requires the applicant for such permit to Glc a signed statement
that he is licensed pursuant to the Provision of the Contractor's License LAW(Chapter 9 Sq.Ft. Floor Area Valuation
a (commencing with Section 7010)of Division 3 of the B usinem and Professions Code)or
y $
Out he is exempt thatch..antl the basis far the alleged escmption.Any violation of rrtea ss.i�nt iso A
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of 3 N�V�dWbl$ezO O Occupancy Type
ROLMOMOwnfivehundreddollars(55oo). P Y YP
1,as owner of the pmperty,or my employees with wages ss their sole compensation,
will do the work,and the mucture is not intended or offend for sale(Sec.70dd,Business
and Professions Code:The Conuactor's License Law does not apply to an owner of Required Inspections
property who builds orimproves thereon,and who doessuch work himself orlhrough his
own employees,provided thmsuch improvements are notinended reoffered forsale.It.
however,the building or improvement is sold within one year of completion.the owner,
builder will have Ne burden of proving Nat he did not build or improve for purpose of
[A I.
❑1.as owner of the property,am exclusively connecting with licensed comments to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
came Law does not apply to an Owner of property who builds or improves themon,and,
who contacts for such projects with a comrseur(s)licensed pursuant to No Chromatin. t
License Law.
❑1 am exempt under Sec. ,B&P C for ON rcazon
Owner Data -
WORKER'SCOMPENSATIONDECLARATION
1 hereby affue under penalty of perjury arc or the fallowing declarations:
I haw and will maintain a Certlrean of Consent to sel6insum for WorkeesCompcn-
aation,M provided for by Section 3700 or Ne labor Code.for the perance
rronof the
w
or which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for the performance of the work for which this permit is issued
My Worker's Cnmpensaziq�In¢uanm carion antl Policy number am:
Cariern s>4. ,Policy No:M R SO b 00 I�.�
CERTIFICq OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This soclion(moil nm hecompleted if tM pdmMI is fnrone hundred dnllm($101)
ter lass)
1 ceniry that in the performmee of the work for which this Permit is issucd.I shall not
employ any person in any manner An as to become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccni ream of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this Permit shall W deemed Revoked.
y y CONSTRUCTION LENDING AGENCY
.� s NnM1y aRrm Nat there iaacomwdinn lending agency for the performance of
Ne work fur which this permit is issued(Sec.3(197,Civ.Cd
A Lender's Name-
z Lender's Address
V C) 1 certify Nat 1 have read this application and sate that the above information is
correct.I agree to comply with all city and county oNinances and sari laws relating to
�
building construction,and hereby autharins representatives of Nis city to enter upon Ns
Uabove-mentioned property for inspection purposes
(We-)agree tc save,indemnify cad keep harmless the City of Cupertino against
iN liabilities,judgments,costs and expenses which may in any wayaccme against mid City
C) 7 in consequence of Ne granting of this permit
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
CEREGU ATIONS.
£' la—/6 U3 Re-roofs
Signature of Applicant,Contractor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hanardous material
az defined by Ne Cupertino Municipal Cods,Chapter 9.11,and Ne Health and Safety
Code. 25532()7
El Y. �Nainspected, All roofs shall be prior to any roofing material being installed.
Will the applicant or future building a¢upam use equipment or dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
it Munches air contaminants as darned by the Bay Arca Air Quality Management all new materials for inspection.
ishict7
❑Yes �-�No
Ihave reul ty he Cod Seconds 25505, requirements and 5534.IrChapter6.95 of the Califnr. ( .
aid Health&Sadly ha dc,danmu, an it is my Responsibility
undersand Nat if the building _//—,/).3
D T
does tau dy hawemnenr,that it is my msportsihilitymnnuly Ne-acupant of Nc _M J
a. cots /}�co�mtj�t—issaanaeoraCm4romAorOccupancy. 'Signature of Applicant Date
All roof coverings to be Class "B"or better'
Owner tar autharivcd agent Dom
Community Development Department
Building Division
jr ) '" ' City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408) 777-3228
Fax: (408)777-3333
SCUPEkTINO
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 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 Ipolicy on re-roofing.
Homeowner's Name: I1 Y' + M r S, C1 A 1\d n
Job Site Address: \(033C5 1 1�- 1 v d
Roofing Company Name: DWY1 G11 1 QTS S�00 yYl pCcM t�
A plicant's Signature: Date: I d -16-O3
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
O �/ Z� ��
REROOF
CUP1cEkTINO PERMIT APPLICATION FORM
APN#
3 f - D Z o Date:
Building Address: I Z V 1 G;—0 3
033 Scev� ic
Owner's Name: C") h -0
s 1 64 i y _1—_ Phone #•
Contractor: QM I �� rr ZGZ �l 1
Phone#: t-(0� —579'— License#:
Contact:
l S D (O -Z 3'Z? (o 11 3 3 T
Phone#: Cupertino Business License#:
t� o r �p u i s � �-559 =132.
Type of Roof Covering:
Existing:
O Built-Up Roof Proposed:
❑ Asphalt Shingles ❑ Built-Up roof
� Wood Shakes ® Asphalt Shingles
it Wood Shingles ❑ Wood Shakes
❑ Other(Specify) ❑ Wood Shingles
Number of existing coverings ❑ Other(Specify)_� S—rM p�L.,(p Z
0 To be Removed bo+1� ❑ Provide Mfgr. In Report#
❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Com 1 With Cul:ertino's Tear Off Polic \
Job Description: ZQry�O� � �ers ay1S trcI
�el� roe "hl � zt� cbxl
t�st1<e�C m rr,be fuss Sh. IQS c\ass W, l� v�a�� w�eta
Residential [� Commercial [] �
Fire Zone: Y No
Confirmed with Plan De t. if
Cost of Pr ect: there are an actions:
(� S �� Type of Construction: Occupancy roup:
_I 2
Qty, if
A h a Fee ID
BPERMFEEFee Description Fee Grou
BENERGY
Bld Permit Fees BUILDING
Ener
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC BLicense BUILDING
usiness
BUILDING