04090300CITY OF CUPERTINO .': .•<. ,`.. .,,
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211 UR �t1TI011
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BUILDING DIVISION" PERMITGONTRAC[Q
BUILDING ADDRESS:
CUPERTINO ROOF, INC
PERMITNO.
04090300
OWNER'S NAME:
PERMITISSUEDATE
ONE:
SANITARY @* 11. NO.
ARCHITECT/ENGINEER:
.. BUILDING PERMIT INFO
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e cr MFICH
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LICENSED CONTRACTOR'S DECLARATION
Job DeSCTI SIO Law --
p
1 hereby air.. her I am licensed under provisions of Chapter 9 (commencing
with S"mn7000)af Division 3 of Ne Business !?0afnssions Cade,mdmylicamch,
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m mB mr9p erceet/ S (o �f 3 -j
Li"nae GIMS ; 5 Lie.p
REROOF OCT /b� 2004!.
Dam Con.=,
ARCHITECTS DE ON
1 undcnlpl�my phos .hell W nscJ as puhlic re"rds
_ _ --' -' "- ^ `- '_11 _
Licensed Professional
OWNER -BUILDER DECLARATION
-' - - -'- ----�
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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following reason. (Section 7131.5, Business end Professions Code: Any city or county
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which requires a permiths cnnswct, alter. improve, demolish, or repair my structure
prior to rs issuanea, also tequims the applicant for such rermitto file a signed statement
that he is [!caused pursuant to the provisions ofthe Conlractori License Law(Chapter9
Sq. Ft. Floor Area
Valu" on
(commencing with Section 7000) of Division 3 of the Businessand Professions Code)or
that he is exempt therefrom and the bash fm the alleged exemption. Any violation of
3 2Wk*TI¢3e10 0
_
Occupancy Type
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
oat mom than Ova hundred dollars (5500).
0 1, as owner of the properly, or my employees with wages as their sole compensation,
Required Inspections.
will do the work, and the structure is notimended or offered formic (Sec. 7044, Business
and Professions Code: The C.moseu , License Law does oat apply to an owner of
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propeny who builds orimproves thereon, and who doessoch workhimselforthrough his
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own employ=, provided thmsuch improvements am notinlended oroffered formic, IL
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Lowever, the building or improvement is said within one year ofcompletion, the owner.
builder will have the burden of proving that W did am build or improve for purpose of
sale.),
0 1. as owner of the property, am exclusively contracting with licensed contractors m
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construct the project (Sec. 7W4, Business and Professions Coce:) The Contractors W.
cause law does not apply In an owner of property who Wilds or improvas thereon, mtl
who contracts for such projects with a conraetor(s) licensed pursuant o the Contractor's
License Law.
0 l an exempt under Sec. ,B&PC for this moon
Owner Dau
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WORKER'S COMPENSATION DECLARATION
I hereby a1Rren under Penalty of perjury one of the following declarelians:
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I have and will maintain a Certificate of Consent to self -insure for Worker's Compere
ration, as provided for by Secede. 37W of the Labor Code, for Ne performmm of the
work for which this Permit is issued.
0 1 have and will maintain Worker's Compensation Imuran", m squired by Section
3700 of the labor Codc,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am'
Gm'ei-L 2 `ZI'� T- U t� V !icy No.:
C/ CERTIFICATE OF EXEW FROM WORKERS'
COMPENSATI NINSURANCE
(This section need no, W completed if tW permit is forone hundred dollam (SIM)
or less.) .. .."'_
1 certify Not in to performance of the work for which this Permit is issued, I shill not
employ any person in any mannerso az M became subject o the Workers' Compensation
'
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. IL after making this ComEeam of Exemption. you should
become subject to the Worker's Compensation previsions of the lahor Code, you most
forthwith comply with such provisions or this permit shall W deemed revoked.
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CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a concoction lending agency car the performance or
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the, work for which this permit is issued (Sec. 3W7, Civ. C.)
Lender's Name
Lender's Address
1 cenify that I have read this application and Stam 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 su burins representatives or this city in enter upon the
an proposes
above ( ei age propeny for ins indemnify
(We) .gree to save, indemnify and keep harmleu the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way seems against said City
in consequence of the granting of this Permit.
4Date-
R (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: -
sogR cuunops�
30
,,9
Re -roofs
Sig/ tore ofApplicanUCommett r Dae
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will tha applicant art (.a.. building occupant state or handle herardom mammal
az defined by the'C vino Municipal Code. Chapter 9.13, and the Health and Safety
aJc. Seatian 25533(a)'
All roofs shall be inspected to any roofing material being installed.::_
❑Yes Nu
. prior . '•
. If a roof is installed without first obtaining an inspection, I agree to remove
Will qpa.applicanl or future building occupant are equipment or devices which
mil ha'rardnus a taminants m JCOned by the Bay Area Air Quality Manegemrlrtt-
new materials for inspection.
District?
❑Yes No
Ihave teaNaNrequirements oldie Califon-
ia SafettySections 2555.25533and25534.1nderstndthatbuilding
dr
ata not ntlyhomlite tthaEitismyesponsihilityMWdfythCMCUPantofthe
\
v I eof Applicant Date
- All roof coverings to be Class "B" or better
ragaiman h dints,et Priarm issuance ora CcrtiRCala artpampancy.
t_ -3o Ci
art tor mmorimd agent Date
i
CITY OF
UPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax (408) 777-3333
Building Department
JOB A ESS:
o -3-TJ��f � � � plq L
PERMIT #
6
OWNER'S
PHO
GENERAL CONTRACTOR:
FAX # '7
A
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the follnwino infnr niHnn-
A*Contractor Signature
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
-30-0(16"
/%ate
e
A*Contractor Signature
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Til
-30-0(16"
/%ate
Community Development Department
Building Division
✓` City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408) 777-3228
14 U p C R,Tl N O 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: 5_0V_1 ` N I^nFa I 1-e
Job Site Address: I O 's IL —f t o c--,
Roofing Company Nan3e:C U +-1 _zJ r C
A plicant's Signati�re:
Greg eel
Building Official
Revised 1/30/03,
Printed on Recycled Paper
V
Date: Ci '3�f5
e
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CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN # iQ
Bldg Permit Fees
Date:
BENERGY
Energy
BUILDING
Building Address:
pk -c--
Seismic Fee Res
c
c-w
wsame: r'F-&, r- I -e
Seismic Commercial
Phone #:
Contractor:
Phone#:� ?
License #: S Is C-1-3 —7
BUSLIC
Business License
BUILDING
Contac
Phone #:.z -r V I, C
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
Asphalt Shingles
---B Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
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: ❑
lob Description: -f< q e 0,4-.Q
S 1,,z\49
Reside�it tial-❑
Commercial ❑
Fire Zone: Yes ❑ __Lie-❑
\ Confirmed with P mg t. if
\ there are any r i tions:
Cost rcjet ^ -�
Typ of Cons ton: \ Occupancy gr
QtY
A ca J
Fee ID
f
Fee Description
Fee Group
BPERMFEE
Bldg Permit Fees
BUILDING
BENERGY
Energy
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING