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CITE' OF CUPERTINO
.C.T IN EIktMATI€IN�
BUILDING DIVISION PERMIT
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PERMIT NO. � yg O
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PERMIT ISSUE ATE
SANITARY NOI CONTROL NO.
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ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 herebyaffirm that I am licensed under provisions of Chapter 9 (commencing
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with Section 7000) of Division 3 of the Business and Professions Code, and my license is
lob Description
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n full force and eff n 2�
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LICenEe CI / LIC. #
Date f 7 Conlrau90r
ARCHITECTS DF_CLA AT10
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A, w �J•+
, V V c J Lam/
1 understand my plans shall be used as public records
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a I C � & A -
Licensed Professional
OWNER -BUILDER DECLARATION
V
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
S Ft. Floor Area
q
Valuation
prior w its issuance, also requires the applicant for such permit to file a signed statement
9
that he is licensed pursuant to the provisions of the Contractor's Liccnse Law (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
'
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
' ..
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construe( the project (Sec. 7044, Business and Professions Code:) The Conuactor's Li-
cense law does not apply to an owner of property who builds or improves thereon. and .
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workees Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Ins cc carrier and Policy number are:
carrierW,1 C.rlt�rl.�,,, A`vt Polley No.: e)l otya 1835 7 -Qt6
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California. Date —
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
" CONSTRUCTION LENDING AGENCY
: I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
~ Lendces Name
'
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rlyj liabitides, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued I)y:
SOUR EG TIONS.
Y21" 7
Re-roo-'s C7—
Type of Roof
Signature otApolicantiContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cede, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ga+o
If a roc f is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
C31131. hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes $No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
Safety Code,
nia Health & Sections 25505, 25533 and 25534.1 understand that if rte building
3.a/4__
does not currently have a tenant, that it is my responsibility to notify the occupant of the
rcyuircmen hich ust be met prior to issuance of a Certificate of c upancy.
7 T
Signature of Applicant Date
* r 910
All roof coverings to be Class "B" or better
Owner
orautho agent Dare
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
a o� „4tq A Cuvu
PERMIT #
0
OWNER'S NAME: 1\)c.vtc ,.:.
PHONE # 4os -q7 -ctsu
GENERAL CONTRACTOR:
FAX # clop - u 6-7 -.o is
I am not using any subcontractors: 4"" 'ly i2``'-7
`signature Date
P1eaGe check annlicable subcontractors and coravlete the following information:
Owner/ Contractor Signature
Date
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/ Contractor Signature
Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
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 i -e -roofing.
2. New roof coverings shall not be appL-ed without first obtaining all inspection
and written approval from the buildi ag inspector. A final inspection and
approval shall be obtained from the L uilding 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 Ci .y, the following steps are
required:
1) Pre -inspection and/or tear off apF roval.
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 withou = first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re -inspection fce of $176.18. The re -inspection fee must
be paid before another inspection can be scheduled.
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: A)ayic-, Ga1ov rel
Job Site Address: I L4 9b )Z sg 6 --de,, Leme
Roofing Company Name: Le j`' W I°i
Applicant's Signature: A-."'�"� Date: ' /2c�
Greg Casteel
Building Official
Revised 11/2/04
OqO 100 5ta
CITY OF CUPERTINO
RF ROOF
CUPERTINO PERMIT APPILJICATION FORM
APN #
Bldg Permit Fees
Date:
i/q' 21r. 7
Building Address:
Energy
1 0 b Roar Ga deo Loi
BSEISMICRE
Owner's Name:
BUILDING
Phone #:
Nt:v►(CAla::,-I
BUILDING
q0t, 25 -L* - 2233
Contractor:
BUILDING
License #:
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L.r c-4
BUILDING
V'c -2-6v
Contact:
Cupertino Business License #:
r, Lu �loa cis
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
0 Asphalt Shingles
W Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
Number of existing coverings
❑ Other (Specify)
❑ Provide I.C.B.O. Report #
JC To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu
ertino's Tear Off Policy:
Job Description:
n: 2A tcrx 304 Cm N1 PA'S.
_ r`
/L 297
Residential f5�_ Commercial ❑
Fire Zone: Yes ❑ No
Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Cons/rt�ructiion: /�) OccupanS y�roup:
14 I OCU Q, - ¢Cr.. r
\i/I /
Qty. if
Fee Descri tion
Fee Group
Applicable
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