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CITY OF CUPERTINO
BUILDING DIVISION PERMITi�+��r1ar
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BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
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AUAWO? 0 0 9 CONTROL NO.
ARCHr1ECf/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
RE -RF T/O& INSTL RF 27SQ OSB CLS A 30YR COMP
License Class Lie. d
Date Contractor
30#FLT SEAMLESS GUTTERS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby al7rrn that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to conswuct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License Law (Chapter 9
1;q. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$11100
that he is exempt therefrom and the basis for the alleged eumption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
36921041 0 0
❑ I, as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
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
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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. IL
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
k..
.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 fo such roje ith a onuactor(s) licensed pursuant to the Contractors
!rise
❑ der B dr P this
License f1pit
Owner I I Date
WORK DECLARATION
I her alrirm un ty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
.rn, 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 Workers 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 arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars ($100)
or less.)
I cenif-v that in the performance of the w rk is it is issued. I shall not
4f, �whi,
employ any person in any manner t Workers' Compensation
Laws of California. Date
Applicant
along is i ption, you should
NOTICE TO APPLICANT: lf,"ahirlbc
ome subject to the Workers Compensation p vi iota of the Labor Code, you must
forthwith comply with such provisions or this per.nWshall 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.)
Lenders 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 authorise representatives of this city to enter upon the
above-mendoncd property for'napcction PurP0!iC .
(We) agree to save, in mnify and $ less the City of Cupertino against
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liabilities, judgm nts, c is ex whi may any way accrue agai said ity
in consequence the ti of is
APPLICA DE DS L COMPLY WITH A N- 1
°
Issued by: Date
SOURCE R LA S
Re -roofs
Signature on te
DO S M ALS DISCLOSURE
Type of Ro :)f
Will the applicantfut building occupant store or handle hazardous material
as defined by the Cupertin unicipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
C3 Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management
ict?
❑ Yes ❑ No
If a roof is installed without first obtaining an inspection, I agree to rem ve
all new mal erials for inspection.
1 have read by us rial requirements under Chapter 6.95 of the Califor-
niaHcalth Safct ode ti 505 533 and25534.Iundcrstvtdthatif it 'ng
does not nil ave tenan my responsibility te notify the acti0ant C the
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require w ' m m p ' issuance of a Certificate o .Occu
$Ig t Date
row.".;
oof coverings to be Class r%" or better
or authorised a nt Date
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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 agiee to comply with 2007 IBC Standards
and manufacturers specifications on re -roofing. All roofs are Class "A" per Cupertino
municipal code 16.04.080.
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 Cit j, 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 nai, 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 per ormed.
7. NOTE: If you call for a plywood nail Inspection and the job is not ready,
you will be charged a re -inspection fee 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 abov ! stated policy on re -roofing.
Homeowner's Name: _ 4&4 ��o s
Job Site Address:
Roofing Company N
Nan
Applicant's Signature:
Greg Casteel
Building Official
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AJ P1 dbA_ Date:
04
Ca
Revised 07/30/08
CITY Of
CUPEkTINO
CITY OF CUPERTINO
RE ROOF
PERMIT APPLICATION
()q0(,, o t oLP
APN #� � � I _ �
Date: / D
Building Address:
A
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Owner's Name: fiAJ)VA Y0-S
Phone #:
HOA: Yes ❑ No ❑ If Yes, provide letter from HOA
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Contractor:
Phone #: YtV 2, z
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Fax #:
Cupertino Business License #:
Contractor License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ 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.C.E.S. Report #
❑ To be Removed
❑ Provide Mfgr. Installation Specs.
Job Description: lAqA b 4 akgP,66
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C.,ass a �n �w C.� �,,
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Residential
Commercial
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation: I I /00,0()
J
I Have Read,
Signature
Will Comply with Cupertino's Tear -Off Policy:
Revised 02/05/09
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CITY OF
CUPEkT1NO
CITY OF C UPERTINO
REROOF
FEE SCHEDULE
Number of
Squares
Fee ID
Fee Description
Fee
Group
Permit Type
1REROOFCOM
Re -roof Commercial
B
1COMMLROOF
1BCBSC
Cal Bldg St�indards
Commissior, Fee
B
ALL PERMIT TYPES
1BSEISMICO
Seismic Commercial
B
1 REROOFRES
Re -roof Residential
B
1SFDWLROOF
1BCBSC
Cal Bldg St�mdards
Commission, Fee
B
ALL PERMIT TYPES
1BSEISMICRE
Seismic Residential
B
1REROOFMRES
Re -roof Multi -Family
B
1MFDWLROOF
1BCBSC
Cal Bldg St mdards
Commission. Fee
B
ALL PERMIT TYPES
1BSEISMICRE
Seismic Residential
B
1BUSLIC
Business License
B
1.
2.
OWNER -BUILDER. VERIFICATION
(Check one) I or my immediate family (p 3rent, spouse or child) will perform:
A �•' All the work authoriz ed by this permit
B. A portion of the wort:
C _ None of the work
If B or C is checked, complete 2 or 3 below.
A state licensed contractor will be hired i:o do:
A All of the work
B A portion of the woi k (complete section below)
Phone # State License # Type of work to
:vr '`
orm
3. _ I will utilize unlicensed person(s) other than my immedbe an iate
employer tf� revery to se side).A r
portions of the authorized work. I understanuct est ation mus be on file at the City of
Certificate of Insurance covering workers co p
Cupertino Building Department office.
Phone Number Type of work to be
PersorvTirm 7::::
Address/City erf o1ed
w
I declare under penalty of perjury
owner -Builder Information (neve:
Property Owners Signature:
b Address•
the above is true and correct. I have read and understan e
e
Date:
Permit # v O
jo
An char es
to the. information rovided c n this form shall be submitted to the Ci of Cu ertino Build
Department.
CITY OF
rUPEkTINO
Buildin
JOB ADDRESS:
OWNERS NAME: Ntv
GENERAL CONTRAC'T'OR: U�
an subcontractors:
0
I am not using y Sign
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
De artment
PERMIT #� C r� C I c)�
PHONE # (YzS 00
FAX #
k. 0m
Date
Signature