04030003 (2) a CITY OF CUPERTINO
BUILDING DIVISION PERMIT VC0 , TRAGT
OINF,Q;RMATIONs.
BUILDING ADDRESS: A L RESIDENTIAL/COMMERCIAL Pr"Mr "04030003
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY N0. CnA
ONTROL NO.
!RCHTTECTMNGINEER: BUILDING PERMIT INFO
RLDO ELECT' PLUMB MECH
il8LICENSED CONTRACTOR'S DECLARATION O O O O
I MWaEy afNm Nat I sem licensed under provisions of Clupmr 9(commencing lob Descripti
M F'HALED
(m Secdttaiiaoen,�7W( )af Division 3aftha Business Professions Code,And my license is
Dmyz in full uaM L REROOF MAR I U ZOO4
Z 1q�. Da¢ Cont es
ARCH
'M aT un�und my pl ns siall M used u public recomis
3at7 Licensed Profeuionsl BUILDING
OWNER-BUILDER DECLARATION
I 1 heathy affmn that I am exempt from the Contractor's License low for the
L10 following moon.(Secdun 7(21.5,Business rad Professions Cade:Any city or county
g which requires a Permit to,construct,Alar,hnpmve.demolish,or lopalr any svuelum
t- Ny priors is issuance,also requires the applicant forsuch permit to file a signed statement
_< that heisllc rand pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft.Floor Area Valuation
S (commencing with Section 7000)of Division 3 of On Business and Professions Code)or
�.. Nat he u Attempt therefrom and%e basis for the Alleged exemption.Any vlola0on of
Section 703"by any Applicant for A Permit subjects the applicant o a civil penalty of ane 3WNXIOftr00 Occas e
Mt mare Nn five hundred do[[.(M).
Occupancy Typ
❑I,as owner of die property,As my employaes with wages as Omit ole compensation,
will do the work and the sbuctum is not intended or offered for tale(See.70".Business
Constitutesd Professions Code:The Constitutesns amt apply M an owner of Required Inspections
License Law da
property wba
builds or improves thereon.and who does such work himself or through his
own employees,provided Nat such improvemanss art our intended or offered for Asia.If,
however.the building or improvement is sold within ane year of nmpledon.the owner.
Wilder will ban the huadn of proving Nat M did nm Wild or improve for purpose of
seam.).
❑1,as owner of the property am exclusively contracting with licensed annactons to
construct the project(Sec.706x,Business and Profogam Code:)The Conosror's U. '
cense law dos not apply to An owner of property who Wilds or Improves theloon,and
who contracts for such projects with a eontracloKs)Intended pursuant o the Contractor's
Lkene law.
❑I on exempt under Sec. .B&P C for Nis mown
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following desti ation:
I haw and will maintain a Cemlicme Cement of Cemeno self-Insure for WorkerYCompen-
sailan,As provided for by Section 3700 of the Labor Cade.for Ne performance of the
work for which this parrnit Is issued.
1 have And will maintain Wokces Compensation Insurance,as em uimd by Section
J7m of the labor Code.far de performance of NA work for which this pmmit is issued.
M Workers Compensation lnsunn nrtimrad Policy number are:
l.
CERTIFI OMPENATIONI MWORKERS'
COMPENSATIONINSURANCE
(Thmseet(on need An,becompleted if Oe permit W forunc hundred dollars(SIM)
or Was.)
I certify Nat in the performance of the work for which this permit is issued.I Nall not
employ any person in any mnarn As to become subject to she Worker'Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If.afar making this Certificate of Exemption,you should
became subject in she Worker's Compensation provisions of the Labor Code,you mug
,J Z forthwith comply with such provisions or Nis Permit Nall he domed invoked.
Z O CONSTRUCTION LENDING AGENCY
[•n► I hereby airline that then its consuuctiam lending Agency on Hep ofmmana of
Qi Oa work for which this permit is Wood(Sec.0097,Civ,C.)
0 Undoes Nurse
,z LandRaMd.
U Q 1 aRify Nn 1 have read this application and sate Nat the above Information W
(p. E correct.l Agree to comply with all city and county ondinnm and sure laws totaling m
L)rVbuilding convection,and hereby authonre opruenutives of Nil city a color upon Oa
slave-marooned progeny for inspection purposes.
gy (We)agree to on,indemnify and keep harmless the City of Cupertino against
t•yy IlahlllUcsjudgments,casts and expenses which may in any way Acerve against said City
V F~jin 7 APPLhis nedt.ICANTeof me Standing UNDEl STAN uStAND WILL COMPLY WITH ALL NOVOINT Issued by: Date
SOURC ULAaLV
Re-roofs
nature a Applic JComoacer Dste
NAZARDO IAIS DISCLOSURE Type Of ROOF
Will Ne applicant ofuture i mo.
g aceupanegore or heMk hnsAaus materiil
As defined by Oa Cupertino Municipal Cade,Chapter 9.13,and f Health and Safety
cede,Section23333(a)?
❑Yes b.
All roofs shall be inspected prior to any roofing material being installed.
will Na applicant a room building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haasNnua air co raminnm defined by the Bay Amo Air Quality Management all new materials for inspection.
District?❑Yes u
Ihave
read
thhnndousmaaAahrets rClMpoat6.93 NCaln
nim Health
&SalcCaa,Sactions]6503,33333 and
25334.1 understandNdifde Wilding
does Out cu haven rat.Om 't ie my mspovihility m notify tW oecapnt of ND
requircmcnm mugI Alp' r i cc or.CcndiieneaOccupncy. / �pgnatureofApplicant Date
O ursuNorivcJ agent Gate N All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
pCITY OF Fax(408)777-3333
UPEI�TIN0
B-- Hding Department
e a tment 2
JOB ADDRESS (��a c>ow S',k) IR� PERMIT#
OWNER'S NAME>0' Aqy,�r- PHONE-#.,d
GENERAL CONTRACTO y FAX #
I am not using any subcontkVA s: 3- Lo u
11 Signature Date
Please check applicable subcontractors and complete the fo owing information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�- Owner/Contr o SignatureDate
Community Development Department
Building Division
� �
o
10City of Cupertino
300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E TIN 0 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 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: UA
Job Site Address:
Roofing Company Name: k
A plicant's Signature: Date:
`JVOV�IL7./�
1 Greg teel
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# ✓ i /ca-,� Date:
KA
Buildin Address:
✓t,
Owner'sName: Phone#:
CLiQ H 1-i b- 4
Contr ctor: Phone#: License :
L. LEY
Contact: Phone#4 Cupertino Business License#:
0 7— 'S
Type o Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof p
Asphalt Shingles Asphalt Shingles f reS^
Wood Shakes Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverin s /'7/11P E3Provide LC.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:
S t ct k t V
Residential Comifierdial FJ
Fire Zone: Yes ❑ No ❑ Confirmed with Planning e . if
there are any restrictio
Cost of Project: / `D Type of Cong tt, Occupancy group:
Qty. 'f
A icable 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
� � 66r