09060129 CITY OF CUPER'1'L
BUILDiNG DIVISION
BUILDING ADDRESS:
OWNER'S IJAME:
ARCHiTECI'/ENGiNEER:
► hcrcyy aCfrm that I sm liccnscd unJcr provisions of Chaptcr 9(commcncing
with Scction 70(M)) of Division 3 of thc Busincss and ProCcssions Codc. and my liccnsc is
in futt force and ct ��5 ���-. Z,
Licensc Clua �- ��• �
Datc Conlractor
ARCHITECI'S DECLARATION
1 widcrswnJ my plans shali bc used u pubiic records
Liccnscd Prufcssional
OWNER-BUILDER DECLARA'I'ION
I hcrcby afGrtn Ihat 1 am excmpt Crom thc Conlractors Licensc Law far 1he
following reacon. (Scctian 703I.5, Busincss and Pcofcssions Calc: Any ci�y or county
which requires a pcnnit to conswct, aller, improvc, dcmolich, ar repair any swcturc
prior W its iuuance, also requires ihe applican� for such permit to file a signed sta�ment
that he is licenscd pursuan� to lhc provisions oC thc Conuacwr's Li�snsc Law (Chaptcr 9
(commencing wiih Scction 7000) of Division 3 0( thc Busincss and Professians Code) or
that he is exempt therofrom end the basis (or the sltegcd exemption. Any violation o[
SecGon 7031.5 by a�ry applicant (or a pecmit subjecu �he applicant to a civil penalty of
not morc U�an fiw hundred dollars (5500).
� I. u owne� of tlrc pcnperty, or my cmployces with wages at their sole campensaUon,
will do �he worlc, and ihe suuctme is not intended or oftered for sale (Sa. 7044. Business
and Pro[essions Code: The Conuactors License Law does not apply w an owner of
propeny who builds or improves thereon, and wha does such wark himsel[or tiwugh his
own employces, providcd U�at such improvements ue not imm�ded ar ofCcred Cor sale. lf.
however, the building or improvement is soid within one year o[ compleGon, the owner-
builder will have tIu burdeo ot proving tAal he did not build or improvc for purpose of
sa1eJ.
0 1, u owner of the propeny, am wcclusively conlracting wi�h lianaed rnntrocWrs la
construct the p�ojett (Sec. 7044. Business aad Profcssions Code:) 7T�e ConUacwr's Li-
cense Law dacs no� apply to an ownu of property who builds or improves the�eon, and
who conmcts [or such pmjects wiW a conuactor(s) licensed pursuant w �he Convacror's
License Law.
❑ 1 am exempt under Sec. , B� P C for this reuon
IMPROVEMENT:�
— 7 ��
pERM1T NO.
n�ntin��a �
PERMIT LSSUE DATE
A O. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
RMV SHK RF �{ RE-RF ADD OSB CLS A TILE 27SQ
35623046
�. Ft Floor Area Valuation
28000
APPd Number Occupancy Type
� �
Required Inspections
Ownu � I
WORKER'S COMPENSATION DECLARATION
I hereby aflirm under penalty o[ pery'ury one o( the following declaretions: I
1 hsre and will mainuin a Certifcale o( Cansent to self-insure for Worker's Compen-
_�on, as providcd for by Section 3700 of �he Iabor Code, for Uie performancc a[ thc
work (or which Ihis pertnit is issued.
❑ I havc and will maintain Workcr's Compensatian lnsurana, u rcquired 6y Scction
3700 0( �he Labor Codc. Cor thc pcdormsnce o( Ihe work for which this permit is issued
M Worker' Comoeosa�ion Insurance carticr Poli numb�,aec�� �
Y �
�
carriu: t�-� .• tP�.t.i` l�v��+�Pd o.:
CERT[FlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectian ucd not bc complc�ed if the permit is fw anc hundred doitars (S 100)
or Icu)
1 cenify that in thc perfom�ancc af ihc work for which ihis permit is issued, 1 shall not
employ any person in any manncr so az w bccomc subject to �he Workcrs' Compensation
Laws of Cali(omia. Daic
Applicant
NOTICE 7'O APPLICANT: If, af�r making �his CcrtiCca�e of Excmpuon, yau should
I become subjett to thc Worlccfs Compcnsauon provisio�s af �c Latwr Codc, yau must
forthwith comply with such provisions or this pecmi� shall6c dcemed revokcd.
CONSCRUCf10N LENDING AGENCY
1 heroby a[Lrtn that thete is a conswction Iending agency far the performance of
ihe wnrk for which �his pertnit is issued (Scc. 3097. Civ. C.)
Lendcr's Namc
L.cnder's Address
I certify �hat I havc read this application and sule thal thc above infarmatiun is
cortcct 1 agrce to comply wi�h all ciry and counry onlinances and sute laws reladng to
building consuuctioa, and hucby autharine representadvcs of Wis city lo cntcr upon �hc
atwve-mcntioned property for inspeciion pur�wses.
(Wc) agree to save, indcmniFy and keep harmless �he Ciry af Cupertino against
IiabiliUu, judgmcnls, costs and expcnses which may in any way acccue against said City
in cansequence oC the granting af this permi4
APPLIC NT UNDERSTANDS A WILL COMPLY WI'fH ALL NON-POI
SOUR � 2 �,
Signuuro of App �canUContractor De�c
HAZARDOUS MATERIALS DISCLOSURE
�11 thc applicant or futwc building occupant storc or handlc ha•rardous mamrial
az defined by tlu Cupenino Municipal Codc. Chap�cr 9.12, and �hc Health and Safety
Cafc, Scction 25532(a)?
❑ Ycs o
�11 the applicant or future building occupant use eyuipmen� or devices which
harardous air contaminants u dcf hy lhe Bay Area Air Quality Management
rici?
❑ Ycs No
1 havc rcad ihe hvardcnu maicrials requiremen� unJcr Chap�cr 6.95 of ihc Califor-
nis Flcalth & Safety Codc, Sections 255U5, 25533 and 75534.1 undcrstand that iC ihc building
docs not curtcnu havc a tcnant, ihat it is my rcsponsibility m noul'y U�e occupant nf thc
a Ccnificaic of Oc
�
Owncr or aut onisd agcni Datc
PERNIIT
Z�fi � �-1 Z
C:
Date �_. 2.�' -��
Issued by:
Re-roofs
Type of Roof
All roofs shall l�e inspected prior to any roofing material being installed.
If a roof is inst�.11ed without first obtaining an inspection, I agree to remove
all new materials for inspec►ion.
Signature of AFplicant Date
All roof coverings to be Class "�.`` or better
=-�,►
4� .
CITY OF
CUPEf�T1N0
CITY OF CUPERTINO
RERO�OF
PERMIT APPLICATION
APN #� �
Building Address: �� 3
's Name:
No ,� I If yes
�. �
s License #:
Existing:
❑ Built-Up Roof
❑ Asphalt Shingles
,�Wood Shakes
❑ Wood Shingles
❑ Other (Specify)
Number of existing coverings
❑ To be Removed
Job Description: `���
�
,�.s-�
Date:
L
Phone #:
ZIG
letter i 'rom HOA
Contractor License #:
� ��"�--�- Z---
l'roposed:
❑ Built-Up roof
❑ Asphalt Shingles
❑ Wood Shakes
❑ ood Shingles �
Other (Specify) �\\�- �-�'��"
❑ Provide I.C.C.E.S. Report #
o Provide Mfgr. Installation Specs.
��� �� v � �
�,�t ��-f�
�
Commercial
Green Building: Please complete relevant portion of the
Green Building Checklist & attach it to the applic ation or if
a licable, inc de in lan set & the sheet i�dex.
Valuation:
a.�,��
Confirmed with Planning Dept. if
there are any restrictions: ❑
I Have with Cu�►ertino's Tear-Off Policy:
Signature
�'o�oE��
�S�
Revised 02/OS/09
=�=�:�_
CITY OF
CUPE�TlNO
Number of Fee ID
Squares
�,
C�
�
CITY OF CUP:ERTINO
REROC�F
FEE SCHEI)ULE
Fee Descriptio�i
Fee
Group
B
B
B
Permit Type
1COMMLROOF
ALL PERMIT TYPES
1REROOFCOM Re-roof Commercial
1BCBSC Cal Bldg Standa:-ds
Commission Fee
1BSEISMICO Seismic Comme�cial
1 REROOFRES
1BCBSC
1 BSEISMICRE
Re-roof Residential
Cal Bldg Standards
Commission FeE
Seismic Residential
:
:
:
1SFDWLROOF
ALL PERMIT TYPES
1 REROOFMRES Re-roof Multi-F �mily B 1MFDWLROOF
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fef;
1 BSEISMICRE Seismic Resider. tial B
1BUSLIC � Business Licens� � B
`ii■�t
J
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
Fax: (408) 777-3333
Building D��partment
Subject: Re-roofing policy for the Cit�� of Cupertino
1. Prior to permit issuance, you must agree tc� compiy with 2007 IBC Standards
and manufacturers specifications on re-rocfing. All roofs are Class "A" per Cupertino
municipal code 16.04.080.
2. New roof coverings shall not be applied w ithout first obtaining all inspection
and written approval from the building in::pector. A final inspection and
approval shall be obtained from the buildizg inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any ro��fing installation.
4. To receive a final sign off from the City, th�� following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark anester installation.
5. If plywood is installed, a plywood nail ins,�ection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new materi<<1 down to the sheathing,
so a proper City inspection can be perforn.ed.
7. NOTE: If you call for a plywood nail insp �ction 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 above st�.ted policy on re-roofing.
Homeowner's Name: � -��
job Site Address: ��� ���o �O 12� C�v��p��—���-� � ��'�` �
Roofing Company Name: ' ���-v..���c � �.`-- `��S''�
Applicant's Signature: ��-- Date: � Z- 2.
Greg Casteel
Building Official
Revised Oi /30/OS