03100176 (2) CITY OFCUPEWrINO
BUILDING DIVISION. PERMIT WCONTRACTOWINFORMATIO
BUILDING ADDRESS: WOODS ROOFING PERMIT NOQ 3100176
10288 VISTA KNOLL
OWNER'S NAME: 2179 STONE AVENUE STE 22 PERMTlssus DATE
INEZ MUSOLF 10/23/2003
HE: (831) 637-5576 SANITARY NO, CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
+00 m
LICENSED CONTRAC 'S DECLARATION• (—� O � O
1 hereby affirm thati.1 em licensed a provision f i 9(Com clog Job Description
with Section]gYJ)o(Diviaion Sof c8 da and in.0 and.y nCais
E in full forte anile EROOF
jaz Licen-Cl N'
rH Dab / Cariliaafdr
EARCHITECTS DECLARATION
4 W I uhdcrsmnd my plain¢hall bound.,.bit
C
public re nNs
U
°0.� Licensed Professional
S OWNER-BUILDER DECLARATION
i<f I hereby arrn.that 1 am cse.pf fru.Ne Contractor's License Law far the
m O following mason.(Section 7031.5,Business and Profanities Code:Any city or county
3which requires a p rmil to construct.eller,improve,demolish,or repair any Uncome $14784
-Z j, prior m its issuance,also requires applicant for such pemtiuo file a Signed smmment
3x< that he is licensed pursuant mthe previsions ofthe Commcbr'sLicense Law(Chapbr9 Sq. Ft. Floor Area Valuation
2HO (commencing with Section 7")of Division 3 of the Business and Professions Cade)or
Q N S that be u exempt therefrom and Ne basis fa the alleged exemption.Any violation of 32613116 . 00
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mare than(w hundred dollars(M).
❑I.or owner of the propeny,her my employees with wages se their sole compensation,
will do the work,and Ne dtvnute is not intended or offered Waste(Sec.7004,Business
and Professions Code:The Conoaclori License Law does not apply to an owner of Required Inspections
properly who buildsnrimprawa thereon,and who daasuch work him-kf or through his
own employees,provided that such improvements are not Intended or offered forsake.IL
however.the building or improvement is sold within on year of completion,the owner. ,
builder will haw Be burden of proving Net he did not build or improve for purpose of
salede
Cl 1,as owner of the property,am exclusively contracting with licensed Contracmn to
covwa the project(Sec.70i4,Business and Professions Code)The Conuacbrs L6
cemeue law docs not apply to in owner of property who builds or improves Ihemon,and
who contracts for such propels with a conmcticr(s)licensed pursuant to the Contractor's
License Law.
[DI /
1 am exempt under Sec. - B k P C for this recon
Owner Date
WORKER'S COMPENSATION DECLARATION (�
I hereby affirm under penalty of perjury one of the following dealt-li(ns: -
I have and will maintain a Cent game of Cavern la-l6imum for Worker's Compere
-tion,a provided for by Barnett 37W of the Labor Code,far thce e performanof the
work for which Nis permit is issued,
1 ban and will maintain Worker's Co.pensauan Insurance,a required by Section
700 of the labor Code,for Nc Performance of Ne work for which this permit is issued.
My Workers Compensation Iamunnec carrier and Policy number art:
Carver: .S-'L Policy No.: 285-03 AR-
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thisscctian need ma Mcamplowdlf the .it H for one hundrtd dollar(glp8
or tea.)
I cattily Nat in Ne perh rromm,of Ne work for which this permit is rued.I shell nut
employ any person in any manner an a to become subject to the Worker!Comp m ation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker',Compensation previsions of the Labor Code,you must
,z forthwith comply with such provisions or this permit shall he deemed ranked.
Z O CONSTRUCT]ON LENDING AGENCY
I berehy affirm that Vert is a communion lending agency for the performance of
x the work for which Nis permit Is issued(Sea.309].Ci,C.)
YQ Lendces Name
z Lender's Add..
C I certify Nat 1 have read this application and scam theuhe above information is
1.F+ Compact.I agree to comply with all city and county ordinances and amid laws relating to
�U building constmetion,and hereby authnrim mprtsenlaliver of this City to Chun upon the
„W drovcmendoned Florally for inspection purposes.
(We)agree to-vc,indemnify and keep harm]ca the City of Cupertino against
CL Iiablliuea judgmcnLL costs sod apemen whi hmvy in any way acerae vgaln--id City
J z in wnsequcncc of rating a! s
APPLICANT U RSTA A L 0 Y A L N N�POINf Issued by: Dat
SOURCE 4
Re-roofs
Signature of
HAZARDOUS
ApplicaDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at furore building c,Chapter
score at handle Health and
-de0hea by the Cupertino Municipal Code,Charon 9.13,and the Health end Sa(cmy
oJ0.5e Y.35532(-)? All roofs shall be inspected prior to an roofing material beim
❑ves ON. P P Y g g installed.
Will the applicant or future building occupant me,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haarda s it conmmim os as defined by the Bay Area Air Qualify Management all new materials for inspection.
nricrt
❑Yes ❑Nu
I have head the haaallous materials regmmmentsundcr Chapinr6.95ofdte Calif.,
in.Health&Sofcly Code,Secuuv25505,25533 and 25534.1 underamnd than fuse bedding
dao nm curers how a Rodin W Y my resp sibilify ro nnuly the ac pont of Ne
mgalrcment mhrB l e a .i-San 9dCCfI1g1:0mof/_hl Signature ofAppl' ant Date
Owner or authorimd agent VA p All roof coverings to be Class "B" or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPEI1TINO
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: �) _Com- ,
Job Site Address: IdZ sjq Y�LO/cam
Roofing Company Name: Qzo(. -� tis
A plicant's Signature: Tc/ Date:
Greg eel
Building Official
Revised 1/30/03
Primed on Recycled Paper
,
CITY OF CUPERTINO
REROOFCITY
CUPEI�TINO PERMIT APPLICATION FORM
APN# P Date:
Building Address:
/Q
Owner's NanoPhone#-
Ztez �'lwss� 732 -0238'
Contractor: Pe#: License#:
Zt) ho s o? d 00 - 0903 3 ;2--S/3
Contact: Phone#: Cupertino Business License #:
ZV
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )K' Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings / ❑ Provide I.C.B.O.Report#
ATo be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read,
9Understand and Will Comply With Cu ertino's Tear Off Policy:
J a ess�fr ��/6 6
0 S acts( .h/Q
Residentiaall7n Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: i5
Cost of Project:- Type of Construction: Occupancy group:
!`f 7,Y9' '
Qty. if
Applicable 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
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