03100221 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORUNFOSRMATION•.
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RGILDINGADDRESS: COSMOS ROOFING PERMITN5p3
630 STENDHAL LA
OWNER'S NAME: 1901 OLD MIDDLEFIELD WY PERMIT ISSUE DATE
CARROLL JEROME J AND ELLEN 1. 10/31/2003
NE: —6373 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
5, B G EO PLUMB MEOCH
i C Zp LICENSED CONTRACTOR'S DECLARATION Job DDSCTI
fw❑ I hereby offirm Ihal I am licensed under provisions of Chapter 9(commencing p G
YW with Sec tion IIde nr f0 ion Sof Nc pu.Sineyyn r,.C. end mylicc cis F 'Nql✓`D
�:<n in full force an (aQ/
n se Cl Lie. st
F Dale O Can'..
FF
ARCHITECT'S DEC ATION DEC 1 9 2003
f W 1 understand my plans shall W used u public records
'0 Liccnmd Pntfcrtienel BUILDING
a OWNER-BUILDER DECLARATION
I I thereby ol'firm'hot I am exempt from me Contractor's License Lew fur the
00 following mason.(Section 011]15,Business and Professions Code:Any city or county
S$ which requires a pctmi1 m canawn,obey improve,demolish,or repair any structure
$8445
_¢< prior m its issuance.also requires the applicant for such Formal to file a signed Montreal
ss
that he is licensed pursuant to the previsions of the ComracmrSLiecres,Law(Chapter 9 Sq. Ft. Floor Area Valuation
Fre (commencing with Section 7")of Division 3 of the Business and Proportions Code)or
,u, $
that he is exempt Ihcrefemn and the basis for me alleged exemption.Any violation of 37540035 . 00
Section 7031.7 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man an hundred dollars($500). P Y YP
❑I,a owner of the property,m my employees with wages as their sole compensation,
will do me work,end the wunuse is not intended or offered fors,le(Sec.7004,Business
and Pmeand.os Code:The Convenor,Lt..Law doe,net apply to,a owner of Required Inspections
properly who builds or improves thereon,and who Cessation work himself or through his
own employees,provided that such improvements arc not intended proffered for sale,If,
however,me building or improvement is sold within one year of completion,me owner
builder will have the burden of proving ma'he did not Wild or improve for p opom of
um.).
❑1.as owner of the pmpeny,am exclusively contracting with licensed contractors to
convect the project(Sec.71144,Business and Professions Code)The Conuacmr s Li.
come Taw does not apply loin owner of property who Wilds or improves thereon,and
who contracts for such projects wit a comractraos)located pursuant o the Convector's
License Law.
❑1 the exempt under Sec. ,B A P C for this mason
1037.1W"
ner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of me following declarations:
I have and will maintain a Cenifcam of Consent to sel6insure for Worker's Common.
on,an provided for by Section 37W or the Labor Code,for me performance of the
rk for which this permit is issued.
I ban and will maintain Workers Compensation Insurance,ss required by Section
of the labor Cade,for me performance ofthe work for which this permit is bound.
Workers Compensation Insurance cartiu and Polity number am:
rier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thaseni m Ked not an completed Uthe pared'is for..hundred dollen(SIM)
or leu.)
I certify that in the perfmmanec of the work for which this permit is island,I shell not
employ any Perron in any manner an m to become subject to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenificem or Exemption,you should
become subject to the Worker a Com maxim previsions of the Labor Code,you must
:`Z forthwith comply with men Provisions or this permit Nall k rimmed revotrd.
ti O CONSTRUCTION LENDING AGENCY
I hereby affirm met there it a convection lending agemy for the Performance of
Y. the work far which this permit is issued(SO.3097,Ci,C.)
ALender's Name
3.
z Lomeri Address
.)Q 1 cenify No 1 have rod this application and state Nu the Move information is
y F cancel.I,gree to comply with all city and county ordinances and sure laws reading to
0 U building convection,and hereby authorine rcpresenutiws of this city to enter upon me
6Wi ahovo-mentioned propcny for inspection purposes.
y (we)agree to save,indemnify and keep harmless the City of Cupertino against
rn
liabilities.judgments.costs and Cartoons which may in any way accrue against mid City
),Z in consequence of the gmming of this permit
^ APPLICANT UND STANDS ND L COMP Y WITH ALL NO .pDINT Issued by: Date V /
SOURCE REGU ONS a /�7/r'
Signamrt of ApplicanUConwRe-roofs
cmr Di—
HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
Will me applicant or rutum Wilding occupant store or handle hevarduus material
u defined by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Sarety
.Section 255324)?
❑Ya � All roofs shall be inspected prior to any roofing material being installed.
Will the applicantar future Wildingicupam use eyuipmen'or lesions Which If a roof is installed without first obtaining an inspection, I agree to remove
11 W.,dous air Cubamittanu u defined Aysthe Bay Arca Air Quality Management
District? all new materials for inspection.
❑Yes SaNk
(have mad lk ksardnvsmareriohmyuirements under Chapmr6.95 of the Califon ,(�J ��.y D ,Vr �S �^a
niaHeslth&SafetyCoCe,Sections 25XI5.2saJ]and 23534.1undersmnd mat i(dc Wilding /d J'` �J.
does not et rcn0y haw a mnanL met it u my responsibility w notify the occupant of the eY
requirements which ustkren prior ler' arm ora CerGficam op Qcupan•1. Signatu re of Applicant Date
go
owner or rte k a olle !a-Mai All roof coverings to be Class "B"or better
1
Ma Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408) 777-3228
Fax: (408) 777-3333
U P E IST I N O
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:
Job Site Address:
Roofing Company Name:
A plicanYs Signature: � .� Date: �2 0/6�
\il/�N1D�JV
Greg t
eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
RERooF 2- 2- (
CUPERTINO PERMIT APPLICATION FORM
APN # rI_ 6 Date: o
T� /off
Building Address: / 3 v
Owner's e: (c� �yLP�tn Phone#:-I5 7 _ G'�f 7 9
Contracto : Pppone#: License #:
. (6SD -74 (._3 7 9 S `i-'1/
Contact:, Phone#:� � Cupertino Business License#:
���e
Type of Roof Covering:
Existing: Pro`pgsed:
Built-Up Roof iZf. Built-Up roof
❑ Asphalt Shingles /❑ 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.-,O L --,n
Residential L Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: Lf
COA of Project: Type of Construction: Occupancy group:
Y114
OfTff
lic ble Fee ID Fee Description Fee Group
I BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
L BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING