04040133 CI'T'Y OF CUPEWUNO ' e
BUUAINC DIVISION PLRMI'1 ) CONTRAC LORtINFORMATION `,
BUILDINGADDRISS: SAN JOSE ROOF MAX PERMITNOO4040133
416 AVENIDA LN
NER'S NAME: PERMIT ISSUE DATE
JEFF GUSTAFSON 1352 CHIPLAY DR. Q4/20/2004
ONE: SANITARY NO. CONTROL NO.
(408) 929-7663
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 O D
°00 LICENSED CONTRACTOR'S DECLARATION
wF I hereby affirm'hat 1 am licensed under,and
Proons of Chapter 9(commencing lob D p�Ign�n E®
�Ziy with Sttlio ] ))of Sof the business and Professions Cndc,and my license is I�rlI�,YY L
j qm ensetCc p ppp C / ( REROOF Y
n Date C ` Lic.V( fQ�Zz7 tG p
[eFlypuyy� Da1C —Z Oa COn Vacla`` ML:%OY
e�a lundc tanJ ARCHITECT' Eff.ARATION MAY 10
004
ray plana shall W used as public memds
JyU
; S LicnscJ Professional OWNER-BUILDER DECLARATION BUILDINGQ
a y 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
K m� which requires a permit to comaruc',aper,improve,demolish,or repair any avucmm O
ymi poorur its issuance.also requires the applicant forsuch permiuo file aligned statement
Ey` that he is licensed pursuant to the provisions ofthe Common's LiecoscLaw(Chapter 9 Sq. Ft. Floor Area Valuation
XI-0 (commencing with Section 7000)of Division 3 of the Business and Professions Coo)or
i Nat be is exempt Ocmfrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of 3 At�e1O 0
nor one door five hundred dollars(1500). OccupancyType
❑I,sowner of thcpropcny,o my employes with wagers their role compensation.
will do the work,and the awmure is not intended or offered for sale(Sec.7040 Business
and Profession,Crile:The Conoactor's License Law doe,nm apply man pwne,of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.It.
however.the building or improvement is cold within one year of completion,the owner.
builder will have the burden of proving tom he did not Wild or improve for purpose of
salt.).
❑1.asr of the property,am exclusively contracting with licensed contractors to
consumer the Pat(Sec.7044.Business and Professions Code:)The,Contractor's U.
me law does not apply to an owner of progeny who Wilds or Improv,;thereon,and
wh onracts fmsoeh projects with a comraaor(s)licensed pursuant to the Contractor's
u law
.
exempt under Sec. .B h P C for this reason
er Data
WORKER'S COMPENSATION DECLARATION
' Ihereby affirm under penalty of perjury One of the following declarations:
I have and will maintain aCenibeau of Consent o self-insure for Worker's Co rat en-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Cale,for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance canner and Policy number aa:
Cartier: P. NU.: _
CERTIFICATE OF EXEMPROM W ORKERS'
COMPENSATION INSURANCE
(Tissection need nm W comple'cd if the Permit is forome hundred dollars(5101)
or less.)
1 cenify that in the performance Ff the work for v#ch the mit is issued,1 shall not _
employ anylperaon in ty c sa�m ftp blec/1
vhc Wo rkcrs'Compcnsation
ApPlicaot a
N 1 ETO APPLI ANT.IF,after making th' sins of of Labor odyou should
c subject m the Worker's Compensation provisions of the Lahr CMe,you must
.J z. rOwith cnmPly with such Provisions or this 111.4ahall be deemed revoked.
'Z'O CONSTRUCTION LENDING AGENCY
[—� I hereby affirm that there is a construction lending agency lot the performance of
athe walk for which'his Permit is issued(Sec.3097,Civ.C.)
C2, lender's Name
z Lender's Add.
U Q 1 cenify Nat 1 have read this application and nate that the above afomn'iun is
D, F carted.1 agree to comply with all city and county ordinances and state laws totaling to
0U building eonswction,and hereby authorise repmumativex Of this city to enter upon the
ahove-meuetwo o property for inspection purposes. ( l
H a (We)agree to save,indemnify and keg hum lass City of Cupertino against
N
liabilities,judgments.costs and cx,.scs which may in yway accntc against said City
anting
U Z in SAPPL OURCA nGUNATRrNS NOStAN�rmu MPLY WITH ALL NON-POINT Issued by: Dale
y-2""Os Re-roofs
rgna um�ApplicanVCumrac'or Date
HAZARDOU ATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building Occupant store or handle to aNOua memo.[
az defined by the CuPcoiW Municipal,Coda Chapmr 9.12,and the Health and Safety
de.Section 25532(x)?
❑Yes IerNo All roofs shall be inspected prior to any roofing material being installed.
Will appncam or(wore building Occupant tau eyuipmem Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
W/ardous air contaminants at defined by the Bay Area Air Quality Management all new materials for inspection.
reel?
❑Yes �NU
I have read the hr.rthms mammals recl.incommus fg&r Chapter 6.95 of the Cali or
ria HwlNSSof"Wh'� od,S 'uns25505.25J In .l understands currant
urrntodng . Zo-o 5�
dos no'e'urt ijrh ant,that it' my In it m noGly the aeupan'of Nc
myui t' mapri isod ec ccmaeamPr(xea atureofApplicant � Da[e
owme _o m nmed agent Dior All roof coverings to be Class "B" or better
Community Development
F. 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
�
CITY OF Fax(408)777-3333 PEI�TINO
Building De artment
JOB ADDRESS:
OWNER'S N ,so. PH # 393_ S C7S�
GENERAL CO CTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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 5a7 75,9se o
Septic Tank
Sheet Metal
Sheet Rock
iTflePA
/Contracto ignature Date
A- Community Development Department
�! Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
fuPEkTINO
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
esstated
jpolicy on re-roofing.
Homeowner's Name: 7 e41 Sbdi
Job Site Address: 1�y�l� /Y II&eyl ola .417 . q C Nperr C 2 9 SO/y
Roofing Company Name: 's Eael 0-5e-
,47 /_!
A plicant's Signature: Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
z �S� �� 3 .- 40-
Building Address:
Owner's Name: q Phone#:
Contractor: Phone#: License#:
Contact: ' I Phone#: Cupertino Business License#:
V i z/�r - SQS
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof �/
❑ Asphalt Shingles Asphalt Shingles /0 yf s• Cemf'
)< 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:
Job Description:.
I ear- �' tia kir dS� $�t-d 3o'*i`e !-I
Residential K Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrict'
Cost of Project: Type of Construction: ' Occupancy grou .
i
Qty f
Ap Uca le Fee ID 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
z