04010031 (2) CITY OF CUPERTINO -
BUILDING DIVISION PERMIT RCONTRACTOR FORMaATION,
BUILDING ADDRESS: T & M ROOFING PERMIT NO 04010031
OW PER'S NAME: PERMrf ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
4995-5191
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ZOo LICENSED CONTRACTOR'S DECLARATION
Job Description
MI homey affirm that I. licensed under provisions of Chapter 9(commoner
with Sen ion 7IXX1)af Div' y3 BusinYa!„dP fcssianx Code,andm liccn a
in full fart y,yjffc N gsas� [ R>�og�
{O{aa i License Clear ic.e '0
Fp Dak Cun Or y /\
eqq�V<]y ARCHITECTS DEC ATION
y2 IundermnJ my planssH eeusedu Tic ATION
Licensed Pm(eaioml \/ y y �
y OWNER-BUILDER DECLARATION
C<E I hereby.(firm That 1 I.S.exempt from theConlns Cn LicenseLew fur the
OO following rcaon.(Section](171. Business and proRssians Codc:Any city or county 4411
5$ which requires a Permit to couwcL altar.improve.demalkeh,or repair any Strucwro )
iy prior to its issumm.also rtquines the applicant for such remit fikasignW statement c/
< that he is licensed pursuant In the previsions of the Comm,vor's License law(Chapw9 Sq.Ft!�a loo/n'/Area� Valuation
y� (commencing with Section 7IXA)of Division 3 of the Business and Proessima Code)or 4 /
.. that he u exempt therefrom and the buss for the alleged exemption.Any violation of
Section 7031.5 by any applicant fon Permit ubjecu the applicant ¢civil Penalty of 3 Occupancy Type
not¢ort Nu five hundred dollen(SSOO).
❑I.u owner of the property,or my employees with wages u their cele compensation,
will do the woh,and thuvucturc is notintended Straitened for sale(Sec.71144,Business Re tailed Inspections
and Prefesslau Code:The Cm nctofa License Law dmf not apply to an owner of q p
property who buildsorimprov thereon,and who dmasuch work himself orthrough his
own employ=.provided Net such Improvements arc not Intended or afraid!formic.IL
however.the building or improvement issold within am you of completion.the owner.
Wilber will have de burden of proving Nn w did not wild or improve fur purpose of
tate.).
❑1,a owner of the property,me exclusively contracting with licensed contractors to
consumer the projeel(Sec.Trust,Business and profusions Code:)The Contractor's Lb
cave Taw does not apply to an owner of property who wilds or improv theseon,and,
who contracts;for such projects with a comnactor(s)licensed pursuant to the Cmuamo's
Licence law.
❑lam..modunder Sea ,BAPCfarthkseemn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afnnn under penalty of perjury arc of de following dmlandou:
I haw and will maintain a CeNficete of Consent to se r.ho um for Wartrfs Compem
anon,u provided for by Section 77M of the labor Code,for Ne pedanm ee of the
wok for which this pemtlt is iannd.
1 have and will maimein Wmtrfs Compensation Imutance,u hequirts by Section
of she laver Code,far she Performance of the work for which this permit is issued.
My Work Cam vai nluunn artier and Polity�nu nny �
Canicrs�C.n� POIINFRO l�I—L E
ERTIFICATE OF EXEMPTION FROM RK 0.S'
COMPENSATION INSURANCE
mirk=am need not wco ndcund if tie permh is fortune hundred dallan(11011)
or leu)
I certify that in the Performance of the walk fm which this Permit is laded,I shall not
employ any person in any manner an w tobecome Subject a the Wmkcn'Com osentlon
Laws of California,Data
Applicant
NOTICE TO APPLICANT:IL after making this Omifiuk of Exemption.you should
become subject to the worker's Compensation provision of the laver Code,you muss
,J Z forthwith comply with such provisions or this permil shall w deemed reveled.
zO CONSTRUCTION LENDING AGENCY
[—� I hereby arrom NU there is a commission lending agency for the Performance of
Ci Ne work far which Nu permit a issued(See 3097,Ci,C.)
W� L ndoes Name
.7 z Lender's Address
V Q 1 certify that I haw mud this application and sure that the aww information Is
Ig,E coma 1 agree k comply with all city and county andearri sole laws relating to
C) rVwilding construction.and wrcby Moria apmsenwiv of this city to env upon the
G ahovo-(We)
property(m i indemnify
an lee ha f•
11....,r (We)agree to an.indemnify tad keep harmkv the City of Cupertino agaimt
1.., fq liabilitiu,judgmenu.costa ands noes which may in any way acme against aid City
V z in consequence of the granting of I is pctmil.
.. APPLICA NDERSTANOS ND WILL CDMPLY WITH ALL NONPOINT Issued by: Date
SOURCE CATIONS.
Re-roofs
Silsdaithe of Applican✓Conuictor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future wilding occupant nam or handle harudous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code prat zss3z(a)] I;KNo All roofs shall be inspected prior to any roofing material being installed.
Will rhe applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
l hautdnus oil mnumt nu a dcfuncd by tita Bay Arca Air Quality Management all new materials for hlspection.
strict(
❑Yes Nu
IhavcrtW the has Nms materials reyvirtmcnu under ChaPw6.95afthe Glifnry J /
ni.HealthlQ Safety Codc.SeeGau 255°5,25577 and 25s34.1 undersand thuifrha wilding
data t eunenlly haws an4 dot iI is my responsibility to notify Ice occupant.(ive
y menuwhichm m IP Rrtoiuu e.of aCenif aflx y Signature of Applicant Date
tune authamad agent Data
All roof coverings to be Class"B" or better
�• Community Development Department
Building Division
1/ City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CIN OF Fax: (408)777-3333
OUPEkTINO
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: ) *)e A5 CAmIM �C-T
Roofing Company Name:
A plicant's Signature: Date:(.
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO p ( o l oo 3
0REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# G LI (I / � ()q I Date:
Building Address: ^ ,s4
euens
Owner I am . P 54`
J
Contractor: Ph o e#: "cense#:
� � v s -s Sas g
Contact: Phone#: Cupertino Business License#:
Fona 3 -say
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles >3� Asphalt Shingles
)d Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings�_ ❑ Provide I.C.B.O. Report#
X To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Polic :,
Job escr" [ion'r�Ar PH � / 1 n� 5 t� 2U fk1 ng SNS
3( end �3DResidential
s-
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with PlanninDe t. if
there are any rest ' ons:
ost of Project: Type of Constru tio, : Occupancy gro
bU
AtQty4al
li Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
ENERGY Energy BUILDING
SEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC I Business License BUILDING
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