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07010164CITE' OF CUPERITNU BUILDING DIVISION PERMIT e� BUILDING ADDRESS: OWNER'S NAME: JNE: ARCHITECTIENGINEER: LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. t 3 I �dd 7Q - License Class / Lic. p Date /` —Contractor 4e',; 6di � O- —G ARCHITECTS DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I 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 prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (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 not more than five hundred dollars ($500). ❑ i, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors 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.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor'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 contractors) licensed pursuant to the Contractor's License Law. F11 am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's 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 Workers compensation Insurance carrier and Policy number are: -7 p Carrier. -s"�V/7C yt'l-1) Policy No.: Udd-- 2?'�_ 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, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensadon 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.) Lender's Name Lenders Address I 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERST NDS A WILL COMPLY WITH ALL NON -POINT SOURCE ) U NS.��� 7 Signature of Applicant/Contractor 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 Code, Section 25532(a)? ❑ Yes 04 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes 0Jo I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements whi beset p fto issuance of a Certificate of Occupancy. Owner or authorised agent Date /a'S c1 c PERMIT NO. �9�Wla, PERMIT ISSUED TE SANITARY NO. CONTROL NO. Job Description -74 BUILDING PERMIT INFO ELECT PLUMB Required Inspections Issued by: Re -roofs Type of hoof —Z` Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new rlaterials for inspection. Signature: of Applicant Date All roof coverings to be Class "B" or better Community Development Department Building Division City of Cupertino 10300 Torre Avenue CITY OF Telephone: (408) 777-3228 Fax: (408) 777-3333 C U i EkT I I \ ® Buildirtz 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 shallbe obtained from th,� building inspector when the re -roofing is completed. 3. All roofs shall be inspected prior tc any roofing installation. 4. To receive a final sign off from the Zity, the following steps are required: 1) Pre -inspection and/or tear off a: 3proval. 2) In -progress inspection approval. 3) Final inspection approval. a) Spark arrester installation. 5. If plywood is installed, a plywoodnail zail 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 of ove stated policyon re -roofing. Homeowner's Name: / A Roofing Company Name: A plicant's Signature: Greg teel Building Official " ft Revised 1/30/03 Prinl =d on Recycled Paper CRY OF CUPEt�TINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Build:in De artment JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # ;0Zf GENERAL CONTRA OT a _ FAX # I am not using any subcontractors: � E-ignature Date Please check avolicable subcontractors and complete the following information: � 7 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 � 7 Owner/ Contractor Signature Date CITY OF CLTPERTINO 01-D I REROOF PERMIT AJPPLICATION FORM APN # 3.� -7a�6 Bld,g Permit Fees Date: /zy Building Address• Energy BUILDING �BSEISMICOM Owner's Name: Phone ##: Seismic Commercial BUILDING BPLANCHK Contractor:Phone #: O Ai License M �00 �JS Business License 2!q I - /0 Contact: LJ Phone #: Cupertino Busine s icee #: Type of Roof Covering: Existing: Proposed: ❑ Built -Up Roof ❑ Built -Up roof ❑ Asphalt Shingles X Asphalt Shingles XWood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles Other S ❑ Other (Specify) �- (Specify) Number of existing coverings ❑ Provide I_C.B.O. Rep rt # To be Removed Provide Mfgr. Installation Specs. I Have Read, Understand and Will Comply Wifl i Cu erti o's ar Off Policy: Job Description: ,► ,C% Residential Commercial ❑ Z j S Fire Zone: Yes ❑ No Confirmed with Planning De5pt. if, there are any restrictions: Cost of Project:, Typeo Coustructi : Occupancy group: , Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bld,g Permit Fees BUILDING BENERGY Energy BUILDING �BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING