04070040 F
ITY OF CUPERTINO "n`=''��%�°"f" ''x" r�'"T`�, "�'�' �k�''•`` YTa�
BUILDING DIVISION PERMIT r CONTRACTQR ZIi�A QRlY ATION`„��
LDING ADDRESS: PERMIT NO04070040
OW NER'S NAME: PERMIT ISSUE DATE
PHILIP KIM N[: SANITARY 0. OL NO.
ARCHITECYiENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
=00 LICENSED CONTRACTOR'S DECLARATION Job Description
:e w❑ I hereby affirm that I w littvcd under provisions of Chapter 9(commencing
n<i raid, Jan tan ) fr Di-i n3nrdte eusnri.,na Profcssi'vn1mr manse is
ja_ License "C L;a�y( is
T REROOF W/ SHAKE
'Z' ° °a\ u ^ O-0 CONTRACTOR: PACIFIC WEST ROOFING
'�W U Jd a V H u a cr
TION
tt ON d 1
3Q� Lmcnscd Pndosmmal
S OWNER-BUILDER DECLARATION
I hereby mRw than I am exempt from the Contractor's License Law for the
I S O following mason.(Section](131.5.Busines and w,demolish.
e u i Calc:Any city da mi
K$ff which mvuims a permit set cnnswct.Iter.impmvc,Ocmnlish,nr repair any xtmcmm
prior In itsiatumm,aso requires the applicant for such pewiuu file.signed mamment
�z< that he is licensed pursuant to the provisions of she Comncmri License Law(Chapter 9 Sq.Ft.Floor Area Val Uett000
¢F$ (commencing with Section loath of Division 3 of the Business and profession Chile)or 4
_
that he Is exempt therefrom and the bale for the alleged exemption.Any violation of
Section 7031.5 by any applicant fon permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
01,as Owner of the property.in my employees with wages m their sole compensation, 36217067 . 00
will do the work.and the someone is not intended orortered for nle(Soe.7041.,Business Required Ins ec41 ns
and Ptohnsions COAG:The Contractors Lice ts,Law does not apply to an owner of q p Q.s
property who builds or improves thercon.and whodoes such work himself oromign his a� {�
own employees,provided that such improvements are not intended or offered forwle.It, vv'{[�it •ate
however,the building or improvemenus wail within one year of Complains.the owncr-
huiader will have tine burden of proving that he did not build or improve for l urpoae of ju
sale). C j
0 1,as owner of the property,am exclusively contracting with licensed conwemrs to S 20 p.1
construct be project(Sec.70",Business and Professions Code:)The Contrazmd Li� �QJ/AIft 4
Corona,law docs not apply to an owner or property who build or improsv thereon,and ]y�
who contracts for each projects with a commaeor(s)licensed pursuant m the Commiserates
License law. /� h�
1 am exempt under Sec. .B&P C for this reason VAI
owner Data
WORKERS COMPENSATION DECLARATION
1 hereby Inner under penalty of perjury one of the following declarations:
❑Ihneand will maintain aCcrtificateof Consenuoself-insum for Worker's Compcm
amid.,Is provided fm by Section 3700 Of the labor Code,for the performance Of the
work for which this permit is issued.
❑I have and will maintain Wmams Compensation Insurance,as reclaims by Section
3]00 of the Labor Cole.for Can performance of the work for which this peorm,is issued.
My Wor Coype�m'tidn lnwn camdu end Paltry number am:
Carrie `+` "T� a�sy NO.:
CEITTIFTCATEOFEKEMPTIONFNOM ORKERS'
COMPENSATION INSUR
flhurctidnrtcednotbecomplciceli!sere Ilisfmonehundmeddollare(SIM)
or less)
1 certify that in the perfomrp Ise of c rk f h ch rmit is issued.l shall not
employ any person in anym t r mm eco c u ' a eWorivers'Compewdon
Laws Of California.D
APPlicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject to the Worker's ComPematjon previsions Of Ne labor Code,you mum
O forthwith comply with such provisions or this Permit shall he accrued revoked.
?� CONSTRUCTION LENDING AGENCY
'e. I hereby affirm Nat them is construction lending agency for the perrormince of
aithe work for which this Permit is issued(See.3097,Civ.C.)
(L) lender's Name,
C I-order's Adders
J C) 1 cenify do 1 have read this application and same them do,above information Is
D.H creme.a agree to comply with III city and county ordinances and sum laws relating to
O U building cdnwuction,and busby authmice repraenmtives of Nis city to enter upon the
r� above-mentioned property(or inspection purposes
(We,)agree 10 save,indemnify and keep hmmaess Be City o(Cupenino against
F'i,t liabilities,judgment.costs and eI,.which mayor any way..against to City
U Z in consequence of the gmnbng Of this
APPLICANT UrDERS DS W COMPLY WITH ALL NON-POINT Issued by: Date
v,
SOURCEREGU O S. I,//\I '4 -1-6�'g
Sign Of Appliedo/Commaeof —p,e �i Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm building Occupamirore or handle hmmdous material
as aef rod by do,Cupertino Muni a Cade.Chapter 9.13,and the Health ons Safety
We.&CO..i5531(a)? All roofs shall be inspected prior to any roofing material being installed.
El yes Nu IF
Will thm applicant or future ildin'occupant sew cyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmafdnus air Connotation.g�-local by dm Bay Arca Air Quality Management all new materials for inspeOn.
District?
❑Yes
(have mad the he sora Is yes cnsundcr CM1apmr695 of the Calding
nixH &Safety ode, ns2 153 53d.l undcrsuMe nexam ht ofthe,
Jars acumendY ro lit y aPd ibililYbca�tmtiffyOdcecua�cyupana of the,
m mmentsw arta is Icemh d levo!) Signature of Applicant :. to
Owner dr:athdrineaagennn a�Date All roof coverings to be.Cl ss "B"o better
Community Development Department
Building Division
!'M_A` City of Cupertino
'J 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
qUPEkTINO 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 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 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 City, 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 nail 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 above stated policy on re-roofing.
Homeowner's Name: �N' �� 'L' n
Job Site Address: ( � S
Roofing Company Name: �f'� F C WAS- lCoo � ' Ci
A phcant's Signature: ' Date:
Greg teel
.Building Official
Revised 1/30/03
Printed on Recycled Paper
i CITY OF CUPERTINO
REROOF p
CUPER,TINO PERMIT APPLICATION FORM
APN# / ,Z � O / Date:
Building Address: 1 ` ��S I J _ I `�
Owner's Name: I t P ,�t M Phone
Contractor:
1>>4C i_ S; oo F, c�34 License#:
Contact: Cupertino Business License#:
o t 0000 020'2.
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Or' Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify) coq
Number of existing coverings ❑ Provide I.C.B.O.Report# ��
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 1oo 47 oQ L L
< IL
Residential Commercial ❑
Fire Zone: Yes ❑ No Y Confirm with Planning Dept. if
there e any re 'coons:
Cost of Project: Type of-Con cti ! Ocpancy g ` r
2.Sono
ca a Fee ID Fee Description Fee Group
BPERMFEE Bldg Pen-nit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
t
PACIFIC WEST
1
12640 Brookpark Rd. • Oakland, Ca. 94619
t Office (510)482-
Llc.No.615191 •3952 Fax (510)531- 1911
CAL PAC Dealer
ROOFING