03080179 (2) CITY OF CUPEWHNO a• . ,�? '"
BUI �LDING DIVISION PERMIT aTRACTOR INFORMATION
M .I
BUILDING ADDRESS: LOS GATOS ROOFING PERMIT N%3080179
OWNER'S NAME: 1771 SMITH AVE . PERMnISSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 298-9399
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O
+Oa LICENSEDCONTRACTOR'S
under
DECLARATION Job Description
Fu 1 hereby affirm that 1 am licensed under provisions of Chapter Y(commencing P
�E with Saci rel ))of Division Sol NC Business and Professions Code,and mylmarew is
I mm Jerre G 7 REROOF
Liccnsc�p i Lic.p '
t'a¢ IVARCHITECTS DE TI N
C 1 understand my plans shall he used J pts lie rcenNs 'N LM®
FFN
5403 L,L'Cn3Cd PRIICSSIona
2 3 OWNER BUILDER DECLARATION SEP
[gy 0 8 2003
<E 1 mason,
,(firm that I ons exempt from the Contractors License Law for the a7C r
m O follwhich
guires I.(genion IDIDs,Business and improve.
d mull Crede:Any city memory
which rots issu a permit re uireouct,altar,rat for m n Permit t or x a sig any structure
SZi that hor n ;censed ,alsorc In the[heapplicantfor CchpermiuUBense, w(Chaed statement
0mp that he isliccnmdpursuanttothePmvisiensnfthe COnuanor'sLicenmLaw(ChaP¢r9 Sq. Ft. Floor Area
[i— (commencing wi in Section 7")of Division J or the Business and Promaxonm Cndejur
les,R$ that he is exempt thcrcm froand Ne basis for the alleged exemption.Any violation of 3 6 215 018 . O O �Y
Section 7031.5 by any applicantapplicant for a permit subjects the applicano a civil penalty of APN Number Occupancy Type
nm mare than me hundred dollars($500). -- - - --. ...- P Y ...-"
El 1,as owner of the property,or my employees with wages as their sole compensation,
will do Ne work.and theswctime is not intended or offered fora.[.(See.70m,Dart s
and Railroad. Coda:The Contractor's Lt..law docs not apply Or an owner of Required Inspections
progeny who builds or improws thereon,and whodoes such work himselforlhmugh his 307 - INSULATION
own employees,provided that such improvements are not intended oroffered ror rate.If, 6O1 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion.the owner. -
builder will have dice burden ofprovingNathedid notWild orimprovefurpurpomof 602 - ROOF PLYWOOD NAIL
.1.j. 603 - ROOF BATTENS
❑1,as owner of die propsny,am exclusively contracting with licensed contractors to -
ennawcttheproject(Sec.7W,Business and ProreasionsCode:)The Continuum's Li. 604 - ROOF IN-PROGRESS
cense Taw does not apply to an owner of property who Wilds or ins proves Hereon,and
who courbi for such projects with a couractor(q licensed pursuant to the Contractor's
Licenm Law.
❑I sm exempt under Sec. B At P C for this reasson
Owner Data
WORKER'S COMPENSATION DECLARATION .. .. _
I hereby affirm under penalty of perjury one of the following declarationslip :
1 bew and will maintain a Ccntfcme of Consent to sel6insum for Workch Compcn. _
ration,m provided(or by Section 37W of the,labor Code,for the performance of she
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
y Wo cr's Compensation Inaunn c carticr�and/P/ylicy number en: ,a.� ,
Ca P. �' r(vgcy No.: ZL 79 -AO_L
RTIFICATE OF E%EM NFROM WORKERS'
COMPENSATION INSURANCE
pMs section need not hecompleted If the Permit Is for Unc hundred dollars($111(q
or am.)
1 terrify that in the perfarmonce of the work for which this permit is issued,l shall nm
employ any person in any manner m u m become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Com perwtion provisions of the labor Code,you must
_ z forthwith comply with such provisions or this perm it shall he deemed revoked.
Z'O CONSTRUCTION LENDING AGENCY
1 hereby arfum that them is a construction lending agency for the Performance n(
Y. the work fur which this permit is issued(Sec.3197,Civ,C.)
1 A lander's Name
3 Lender's Address
J Q 1 certify that 1 bow read this application and state that the above infmmadirs is
y P torten.l agree to comply with all city and county ordinances and some laws misting to
�U building construction,and hereby IMMMOC mpresenmiwe of Nis city to enter upon the
G about-memiorod property ran inspection purposes.
ti (Wc)agree to save,indemnify and keep harmless the City or Cupertino against
fy7 liabilities,judgmen;,cos;and expenses which may in any way accme against mid City
U Z in consequence of the gmatin,of this permit.
^� APPLICANT NDERSfAND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCER TIV91A
ONS.
eaclur
j9�3 Re-roofs
igneturc olAPp hcaHAZARDOUS MATERIALS DISCLOSURE Datc Type of Roof
Will the applicant or future building UCCUPant Start or handle harudous material
u defined by the Cupertino Municipal Code.Chapter 9.11,and Ne Ifcaldo and Safety
Code.Section 25532(a)7
❑Yes W. All roofs shall be inspected prior to any roofing material being installed.
'
Will the spill CaM or future buil ding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havaNnm air contaminants u darned by the Bay Arca Air Quality Management all new materials for inspection.
mrlft7
UYq VNU
the.&Suet the hmaNnus am;2555,2553l. and 25534.1 u ChapmrR9tifu,Cali(no- J�
nose Health ur Safety Calc,Serem;hat it i 1M y MaWnss3a.I undcrsianJ theti(the building
dna not currently M1aw a¢nano that it is my raapomihility m ramify the occupant of the
reglhiremcn;w 'h INmct 'Urwissuancco(aCcrtfra¢Uf eupaner. Signature of Applicant Date
weeruraumnr a assn, -� D„e All roof coverings to be Class "B”or better
Community Development Department
l1 Building Division
aE City of Cupertino
,gm
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
qUPEkTINO
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 canbe 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 policy on re-roofing.
Homeowner's Name: !
Job Site Address: 14 �i17SF7�p1Q 7sL
Roofing Company Name:
A plicant's Signator Date: 29�jp
I \N�1/110t.Xi
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO G 3 g c:) 7
REROOF
• CUPEf�TINO PERMIT APPLICATION FORM
APN # Z� (� O / Date: F-29 -03
Building Address: I
/D/ .2 mow, k .!'O y
Owner's Nam Phone#:
L 44
Contract o : Phone#: License#:
Lar/Y- %Ar-, x-/233 800709
Contact: Phone #: Cupertino Business License#:
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 Comply With Cu ertino's Tear Off Policy: ❑
Job Description: SK 4 / /
OA WA 091d
f &I'li 6f-�oq4KIC 7L
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plannine-Dept. if
r—. there are an res ' tions: LJ
Cost of Pro' /� ype of Constructi Occupancy gro
Qty. if
A lic 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
2 z �