02040033 CITY OF CUPERTINO
BUILDING DIVISION, PERMIT CONTRACTOR INFORMATION:.
OUILDING ADDRESS: PERMIT NO.
19624 HOMESTEAD RD BLACH CONSTRUCTION COMPM Y 02040033
OWNER'S NAME: APPLICATION SUB DATE
14 (GOOD SAMARITAN UNITED METHODIS 1650 LAFAYETTE ST 04/08/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 244-7100
O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
<U BLDG ELECT PLUMB MECH
y m i LICENSED CONTRACfOR'S DECLARATION 70b DesCRPCIOn
Oy_C thereby affirm that l am licensed under anvisioas of Chaplet 9(commencing
F=t. with Section7000)ofDivisionSoftheBusiCssandProfessionsCmi,modmylicense REROOF REPAIR.
zmf is in run(tgeartayfer.'_0� ..# 79fjL'1• 9. .
d,or
is in feC$ d Lich_
je a V nu! �n.C-/J7 Com ;IRVI
w a a ✓T ARCHITECT'S DF, RATION
F•-O S I understand my.plaa,shall be used as public records
yy
Y a O O Licensed Professional
o OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Convector's License Law for the
?< followingrcazau.(Section 7031.5,Business add Professions Code:Any city or county' $75000
which requires a permit to construct,alter,improve,demolish.or repair any structure
w 3 m .,Polar to its issuance,also requires the applicant for such permit to file a signed smmmern
th ntialicerceE purstralm o th'provisions of the Commodes License Law(Chapter 9 Valuation
(e6an oit uhSecdon.70110)pfDivisioa3ofrhe8uineuandPmf ioasCode) �:`,�)'+°ti33;1' Sj0 19orheaF,l�;l S•�•a�,y :
or[bar
be Is ez mpt therefrom and the basis for the alleged eiafoptial.Any violation
-of Section 7031.5 by any applican for a permit subject,that applicant m a civil penalty" \
''-of not more than five hundred dollars(8500). 305APy l�N t•::.,,. Occupancy Type
ID 1,as owner of the lonparly,or my employees with wages as their sole compensation, Q
-will do the aoark,and rhe nmcturc'ts not'intended'or offered for sale'(Sec.]Olt, '- - -- --- - --'
Bn p, _ --
s s ad Code The Contractors License Law does not apply in an 6 01 - ROOF TEA]Ae Inspections'
owner of property Who Wilds or improves thereon and who does such work himself
or through his own employees.provided that such improvements are not intended or 6 0,.2-.-- ROOF PLYWOOD NAI L
-
',aRhQfo sale owmar Ile-M1avet -_P- rotn sola wt hat one build of
"- -
603 - ROOF BATTENS
completion,the owner budder will have the bother of proving that he did not build or
improve for purpose of sale.). 604 - ROOF IN-PROGRESS
❑L as owner of the property am exclus vely contracting with licensed contractors to f• ... 1. '!
'omenot'the piojeel(Sec.7pW,Business and Pmfessions Cade:)The Contractor's 'i,l
License Law does not apply N an owner of pmpcny who builds or improves thereon, "
_end who contracts.for such.pro .
iects.wids,couracouni licensed furuan
at.to the _._ .._...__._"..._._....._...._.....__..._. _ ---_
Contractor's License ._. .. ._._. ..._ _._.-_..-_- ----
._.
❑1 pt under
R<c f '1 ' r B&PCfor[hsrtason f9IN � Y ED s.!n,
_ Owen " '1 Date t ' „ 'v e"y�s' i�
WORKER'S COMPENSATION DECLARATION �oOxw
I heo:by eBlrm under,penalty,of peijmy one of the following declarations: DEC 18 L
+ -1 ❑ I hdve'me will'"maintainai Cenificme Of Consent too'selhinsurc for Worker's
Compensation, ax„previded-for by-Section 37W ofthe-Labor-Codc,-for the gVILDING
_ perfa nce of[he work for which thisw
t permit is iscd.,
❑1 have and wdrmalnm W rke7s Compensation Insurance is regoircd by,Section
' 3700 fihe Labor Code'fes ih performance of the w k f -' hl h rhis permri is "
issued My wo ke7i C mpensauon Ins ace d P h y number art'
{ s'CERTIPICATION OF EXEMWION PROMWORKERS f"" �. �,l N' f i,.l., i.,3 11.a,, 4'1e.
COMPENSATION INSURANCE a a i '' _
oli-fl x ITTrs sector i'recd not be complhi:a if the permit is for one hundred dollars ,
(81W)or less.) `
e f th o a f 'whmh th s' t o Work 1
`Iry lc mty that th pert-rat pe II �I
rsh 11 �temploy adypc nanymann_erw iv bccbmes63 cues theWorkers
C m bsa[ion Incas f C I'f'mia:Dere '" " '
:NOTICE TO'APPLICANT:JB.`x Ci5r-rearation thisCarolinaof
Labor Coca,yeshould ,. vi':`.h'. '" •-`r•i: i ':a.
"O bccome'iubjmp y the such ps vision mhos Amit shaof the Labor f Coca,you moxa
fonhwbh comply with such provisions or permit shall be deemed revoked.
' �- "v CONSTRUGI'ION LENDING AGENCY
P:,4 ;' Ili by,Kiat that th bntmcit nlendmg 3S ryfa the perfodn ce' sec.•. r .r• '.is \,: '
[� r of dm w rk for Nch th pe ti i sued lsec 3097 C v.C 1 _
1 ttmfy that 1 have read rw ppl at nand nam thanh ebo e'nfo u is
❑a tr c6rtect 1 agree to comply rth all aty and county oNmnntts end smm laws
admin,
�'�:fJ to buildingmnswction:antl heretiy nuthodu rt'prcsenmtives ofthis city mercer upon
�sgg7 the abbvememiboedprbpcny for inspemioppurposcx. - . .
_F.:"q (WeJagree`6 sane.indemnify vee keep harmless the Ciiy of Cuperiin'o'again
V1 liab In es a dg amt n is and expenses h ch y any qy occme against said
V Y C ty s C ce of the g df th permti - " /V/ `�
APPL1Cp DERST AVD\VR.L COMPLY WTTH,LL YON-POINT"
DO R Issued by: Date
—�j Do., i
Sign Nt<ofApplca JC t t r - ''-r - -"'. 'Date;, Re-roofs
is HAZARDOUS MATERIALS DISCLOSURE s'
Wil the pphsant6ifutiiie Wilding occuporat store prh rMlc hazardous mm rid -Typeof Roof _.._-..._ . ..._..__. ._..... _..., .,�-._ .
a5 d fi ed by theC pertmo Municipal Code Ch pt 9.12 and the Health d Safety r. Q, ! s V.� ,, 1
Cro OY n25511 ) , it- S s )i` j' h �t !y'l sell I, U:
[I" All roofs sfiall be inspected prior to,any roofing,material being,installe
can m .pph t r mare bu_lmmgOccupant. cq p devices lire^ If a roof is installed without first obtaining an inspection;I agree:[o'remove
emit h dour a r t as defnan by theBay Area Air Quality Management
R mel all new materials for inspection._ Applicant understands and will comply with
:oN`. t �q all non point source re- lations:.:r1.r.
I ha read Ne haiardaus.mmenals q me is u der Chapmr 695 of the /
California Health&Safety Code S cdons 25505 25533 and 25535 I ruchurtmordthat
if thehoodng does polemically have at am it that my rcnponab'Ity to notify the /9 r -cam
oc pant of rhe regu menta h be,met p or to issuance of n Cenificam of �'� i f "I
'T Qcupa y mon _ _
Signature of Applicant ate
v ne rsu[hm sell gem I Dam" All roof coverings to be Class 'B"or better
OFFICE-- ---. ... .._ ._ . . .. .
A ACCORDANCE W"iN 'I'!'V
r
NED 9
e kept or
IQIhTpi to C'f"::i " ... .. .. .
iY hH111P Ln ,
September 25;2002
0 m- r
City of Cupertino
D U Q U E T T E 1300 Torte Ave.
E N G I N E E R I N G Cupertino, CA 95014
Attention: Building Inspector
10 south Third$freer Subject: Good Samaritan Methodist Church Roof Repair—PC#2040033 and
' Sin Jose, CA 95113 PC#02050137 �� /�� �%������"✓/
None:(408)494-0944
Fax: (408)494-0940 The new roof sheathing has been changed to W' plywood which will be fastened
with 1/2" crown x 2"x 14gage staples Gia 2" o.c. edges and 12" o.c. in the field. This
mruu<duguette•eV..eom is in lieu of the 3/8" plywood fastened with 8d nails®2" o.c. edges and 12" o.c. in
• the field which is shown on the approved drawings.
The Plywood thickness has been changed to match the existing thickness and the
fasteners have been changed to minimize splitting of the framing. Please see the
attached ICBG report. The new 1/2" plywood with staples has a capacity of 530#/ft
which is acceptable.
If you have any questions or require any additional information please call.
Sincere] ,
Stevan P. Duquette SE SEP 5 2002
i President
• B
JOB
)...
P1
1~'\t
p 9�
• ON! !� lli Q.• ll f�Ti�
tpi p SHALL A���y 1 c t UP rate/
•�:Ii 1W� T RillTWOA` &M�s'F` I• t`.(\\
i
E' . . ::F C::4•. ,ice
,tiurhrni..rd 11rnr/icC;ill: •'�.____._�..�-
.ler;inf 1'rnuiiG.i.
Cogwrnte Offices
Materials/Chemistry tebomlones-
DC1
415CildD962ive DYNAMIC CONSULTANTS INC.
Mountain View,w,malhifomlo 990432216
Telephone: (650) 6982 s 0 ✓ B.n,h Offi,e
Facsimile: (650)%71 55 Testing&Inspection services Watsonville,California
November 14, 2002/cnc
City of Cupertino DCI No.: 7016-MOl
Building Inspection Department Permit No.: 2040033
1.0300 Torre Avenue
Cupertino, California 9501.4 0 aQ�40033 RECER '1:4�D
PROJECT: ROOF REPAIR & UPGRADES NOV 11Q9 2002
19624 Homestead Road, Cupertino, CA BY: ,4G
SUBJECT: Affidavit
This is to certify that, as defined in Section 1701 of the California Building Code, we have provided
those special inspections listed below:
1. Field welding of structural steel
2. Installation of epoxied anchors and rebar dowels
0ihe following special inspections were not performed by this agency as request for this work was not
eceived:
1. Shop welding of structural steel
The completed inspections noted above were performed by personnel under the supervision of the
undersigned Registered Civil Engineer in the State of California. Based both upon inspections
performed and upon our substantiating reports, it is our professional judgment that, to the best of
our knowledge, the inspected work was performed in accordance with the applicable workmanship
provisions of the California Building Code, the approved plans, specifications and Project Engineer's
revisions.
Respectfully submitted,
DYNAMIC CONSULTANTS, INC.
_,✓ "`�- , eta.-,.
No.23,--
Clifford N. Craig
\\'a
cn_
Registered Civil Engineer, No. C26926
lc: Good Samaritan United Methodist Church/Joe Doll/Cliff Ludwig
lc: The Steinberg Group/Thomas Lawrence -
eDuquette Engineering/Steve Duquette
c Blach Construction Company/Steve Dunne
Dependability.....Credibility.....Integrity It's the foundation of quality assurance for your project. At DCI,we built it into our name.