07110108 CITY OF �iTPERTINO
BUILDING DIVISIO�1 PERMIT >����:��'(�� �����T���
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BUILDING ADDRESS: PFRMIT NO.
10461 MADERA DR COSMOS ROOFING 07110108 .
_ .�NER'S NAME: P �T `��
THEODORE COLIN 1901 OLD MIDDLEFIELD WAY 11/19/2007
PHONE: J7� 7 7 SAMTARY NO. CON7ROL NO.
(650)969-7663
ARCHI'I'ECC/ENGINEER: BUILDING PERMI'C [NFO
BLDG ELECT PLUMB MECH
� � � 0
� O p LICENSED CONlRACCOR'S DECLARATION JOb DeSCT1pUOfl
;� 1 hcrcby �rm that 1 am licenscd under provisions af Chaptcr 9(commencing
v � witA SccGon 7000) of Division 3 of ihc Busincv and Profcuions Codc, and my liccnsc is T/ � EX S TNG WD S H K, 1 LAYER , RE S H E ET � S B� 3 � L B
�� infullfotceandef(e �. L � x � `S/q'� FELT� L?1NDMK TL COMP SHINGLES
' � Z Licenac Clgss
f, p Datc f! �- —U 7 Contracar
ARCHITECI'S DECLARA770N
��< l undcrstanJ my plans shall be used as public rccorda
a
; W y Licensed Prufcssional
A,� � OWNER-BUILDER DECLARATION
1 Ncrcby uffirm that 1 am raccmpt Gum ihc Conuactors Liccnsc Law for Us
� p O following rcason. (Scction 7031.5, Busincss md Profcssiont Calc: Any ci�y or county
�$� which rcquims a pc+mit to conswct, altcr, impmvc, dcmuhch, or iepair any svucwrc
y Z y prior w ilc issuancc, alsu tnquims ihc applicam for such permit to filc a signcd siamment
< ihat he is licensed putsuant to the pmvisions of thc Conuactor's Liccnsc law (Chaptcr 9 Sq. Ft. Floor Area Valuation
� t = - $(commcnring with Scction 7000) nf Division 3 of thc Busincss and Profcasiona Codc) or $12 510
y �.. that Ae ia exempt thaefrom md ihe bssis Cor the allcgcd eumption. Any violauon oC
Section 7031.5 by a�ry applicant for a pem�it subjecu ihe applicmt to a civil penaity of Number Oeeupaney Type
not more �han five 6undred dollars (SS00). 3 2 6 3 5 0 4 7�S�
❑ I. u owner of tAe property. ar my employces with wages u the'v sole crompensation,
will do ihe woric, and ihe suucture is not intended or of&red for sale (Sec. T044, Busi�xss Re uired Ins eetions
and Rofessions Cade: The Convacwr's Lianse Law dois not apply w an owner of q P
propeny wtw builds or improves �hercon, and who does such worlc himulf or �hrough his
own employces, provided ihat sucA improvemen�s are not intended or otfered for sala It,
however, the building or improvement ia sold within one yar of compleuon, the owner-
builder will haw the burden o[ proving �hat he did not 6uild or improve Cor purpose of
sak.).
❑ 1, u owna o[ the property, am exclusively conuacting wiih licenxd rnnuactors b
construct Uie pmjett (Sec. 7044. Business and Professions Code:)'[be Contracwr's Li-
cense Law dow oot apply to an owner of propeny who builds or improves ihe�eon, and ,
who conuacta tor such pmjects with a contractaKs) Iicensed pursusnt co We Convactor's
' �cense Law.
` am aempt undu See. , B dc P C for this reason
vwner Dale
WORKER'S COMPENSA'ITON DECLARATION
1 demby sfiirm under penalry o[ perjury one of the foltawing declaraGons:
❑ I hs.x and will mainuin a Cenificate of Consent to u!f-insure for Worker's Compen-
sation, u providcd far by Section 3700 of the Labor Code, far �he performance of thc
work for which Ihis permit is issucd.
havc and will mainlain Workcrs Compensation ]nsurance, u �equired by Section
of the Labor Code. Cot Ne performance of Ihe worlc for w6ich Nis permit is issued. '
My Worke{s Compensau�on ce cartier and Policy numbcr a�e:
Cartier. ) a_� '� �'� Policy No.: � 7l` �J � L Z 5'�
CERTIFICATE OF EXEMPfION FROM WORKERS'
COMPENSATION INSURANCE •
(This sccUan necd irot bc compietcJ if the pertnit is for onc hundred dollus (;100)
or Icu) •
f cenify that in the performance of ihc work fw which �his permit is issucd, I shall not
e�nploy any person in any manncr so u to 6ccomo subject to the Warkcrs' Compensauan
Laws of Califomia Datc
Applicant
NOTICE 7'O APPLICAM: If, af�cr making U�is CcniGca�c of ExcmpGon, yau should
becane subjcct �o the Worter's CompensaGon provisions of �he Latwr Codc, you muu
� O fonhwilh comply with wch provisions or tAis permi� shall6c dccmcd rewkcd.
z "" CONSCRUGTION LENDING AGENCY
E r►��. I hero6y aRirm Uut thcre is a consuucdon Icnding agcncy Cor thc perfortnancc uf
p(, � Wc work for which this pertnit is iscued (Scc. 3097. Civ. CJ
W� Q Lendcr's N�mc •
� z C.cnder's Addmss
V � ► cenify thst 1 havc tead Wis spplieuion and sta�c �hat Ihc above infortnadun is
w� cortccL ! agrce to comply with all city and counry onfina�es and su�e laws celating to
0 U building conswcdon, and heieby authorix represenlativcs of this ci�y to cntcr upon Ihc
� w ahove-mcntioned property for inspection purposes
(We) agrce to save, indcmnify and keep harmless �he Ciry of Cupertino against
H� liabiliuu, judgmcnts, cosu and expenses which may in any way acauc against seid City
V z in consequencc oC the granting of this permi�. Date
� APP NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b �:
S EGULATI S. �
- - ��' `v Re-roofs
SignaturcolAppli ✓Conux Datc
OUS MATERIALS LOSURE Type of :Zoof /�
Will Ihc appliant or futurc building occupant storc or handlc ha•rardous ma�crial
efincd by Ihe Cupenino Municipal Codc. Chaptcr 9.12, and the Hesllh and Safety
_.,� Scction 25532(a)? � All roof:; shall be inspected prior to any roofing material being installed.
❑ Y�
Will the applicant or future building occupant use equipment or dcvices which If a roof is installed without first obtaining an inspection, I agree to remove
emit harardous air contaminants az �lcfincd by the Bay Area Air Quality Managcmcnt all new � naterials for inspection.
Disuict?
❑ Ycs Q.Ko
1 havc mu1 the ha�ard � matcrisls requi�emcn�s undcr Chaptcr 6.95 of thc Califor-
nia Hcalih & Safcty Cadc. Sec�ions 25505.25533 and 25534.1 undcrsund thu i[�hc building
dooeeyy�� ffo��t urtcntly havc a tcnan4 �at it is my responsibiliry w noufy Uu occupsnt of thc
rc 'q�cQqs� hich m ee met �o to issuaricc o[a ccnifica `r �P�r. Signatur�; of Applieant Date
�'f �' �`� All roof coverings to be Class "B" or better
Owncr or authorize agcn Dalc
�"�//�I��
-� CITY OF' CUPERTINO
���-' �::Rt��r
CUPEI�TINO PERMIT AP�'LICATION FORM
Date: � / /S � T
APN # � ,.� / �� � � � /—
p< <.P
Building Address: (� �--�
/O! �/��/��l ��� �r
Owner's Name� J � � Phone #:
<< GJ ��� �-jp� Y.3J- a�s�"�9
Contractor: � License � �
y ` � 1'VI � �CJ7�`7" "�� � .
Conta t: Cupertino Business License #:
� /e (� SO - 1�6� �6 b3
Type o F Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles � Asphalt Shingles 3Y7 �/
❑ Wood Shakes ❑ Wood Shakes
� Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
N mber of existing coverings ❑ Provide I.C.B.O. Report #
� To be Reinoved o%S+ ❑ Provide Mfgr. Installation Specs.
!'
I Ha�e Read, Understand and Will Comply With Cupertino's Tear Off Policy:
Job Description: � �
,��� s--��� � sk �q er ';es�e,�f C�SQ /6 �� �.d r�r k� i� C'o s�,w; �
Residential Commercial [] � �
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: /Z �`� Type o���truction: Occupancy roup: s `/�
��
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BLTILDING
BSEISMICRE Seismic Fee Res BLJILDING
BSEISMICOM Seismic Commercial BLTILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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 a� ree 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 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 C ty, the following steps are
required:
1) Pre-inspection and/or tear off ap��roval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed, a plywood n,iil inspection is required.
6. Any roofing which is applied withoi�t first obtaining an inspection,
will require the removal of all new niaterial down to the sheathing,
so a proper City inspection can be pf�rformed.
7. NOTE: If you call for a plywood na:.l inspection and the job is not ready,
you will be charged a re-inspection f ee 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 "/4 " per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be c�n the job site at the time on inspection.
I understand and will comply with the ab��ve stated policy on re-roofing.
Homeowner's Name: / G� e � c � � e � ' ` '�
Job Site Address: �� �l 6 � %� � ��r � �'
Roofing Company Name• �-f�S� � S ` !1 U�7'� ✓�
Applicant's Signature: Date: �- ��V 7
Greg Casteel
Building Official
R��vised 11/2/04
CITY OF CUPERTINO
2 ITEMS OF 2 PERMI�.' RECEIPT OPER.ATOR: pdtq
COPY # : 1
Sec: Twp: Rng: Sub: Bl]c: Lot:
APN ......... 32�>35047.00
DATE ISSUED.......: 11i19/2007
RECEIPT #.........: BS)00003281
REFERENCE ID # ...: 07L10108
SITE ADDRESS .....: 10461 MADERA DR
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA ..•••••
OWNER ............: THEODORE COLIN
ADDRESS . : 1C461 MADERA DR
CITY/STATE/ZIP ...: CI:PERTINO CA, 95014-1133
RECEIVED FROM •• "; CCSMO�S,ARICHARDY LIC # 18844
CONTR.ACTOR .......
COMPANY ..........: CC�SMOS ROOFING
ADDRESS ..........: 1�01 OLD MIDDLEFIELD WAY #22
CITY/STATE/ZIP ...: MC>UNTAIN VIEW, CA 94043
TELEPHONE ........: (E �50)969 - 7663
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC __NEW_BAL
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BPERMFEE VALUATION 12,510.00 201.96 0.00 201.96 0.00
BSEISMICRE VALUATION 12,510.00 1.30 0.00 1.30 ______0_0
TOTAL PERMIT :
203.26 0.00 203.26 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ----------- -
CREDIT CARD 203.26 MC
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TOTAL RECEIPT : 203.26