04080192 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CL)NTRACTORINFQRMATIO
7x4
BUILDING ADDRESS: FOUR SEASONS ROOFING PERMITNO.
OW NER'S NAME: PERMIT ISSUEDATE
ONE: SANITARY WO. C NTROL N0.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION O O
w 1 hereby affirm that I am licensed under vro f chapter 9(commencing Job D¢S rip 1 n
with seclm )af Diviaian3of me Basine W nsCode.antl mylicanse is
in full fort d cffc. SEP ZZ 2004
�'p= Lieentt Lie.a 'IZtOg REROOF
Zr o Dam —O Contrxmr C,w s !
ARCHITECTS DECLARATION I
try�pq�ny
1 understand my plans shell be,used m
J public mrds U Li p
JyU
C
Licensed Professional
to 5 OWNER-BUILDER DECLARATION
1 bemhy alTrm roes I Am exempt from the Cenoaemea License Law for One
OO following mason.(Salon IID I.S.Boni cat and Professional Code:Any city or county
tie mfLi which requires A permit m ennswm,alter,lmpmw,dcmnlish,Or mpoll any swmoa
FIy prior to its issuance,also requires she applicant for such permit to G lc a signed statement
< that he is licensed pursount m the provisions of the Contracmr's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
zHO (commencing tui th Section 7")of Division Sof Be Bu;inasand Pmfcavam Calc)or
C. that he is exempt therefrom and the hasu for tha Alleged eumption.Any violation of ,r,��U1.irM�w.A
Section 7031.5 by any applicant for a permit wbjccrs Be Applicant to A civil penalty of 3`[x PJ WDO'e 0 0
not mom men five hundred d.H.($soo). r Occupancy Type
❑I,As owner of the property.or my employees wire wages As their;ole compensation,
will do the work,and Be structure is not intended or offered for rade(Sec.7004,Business
And Professions Craft:The Comracmrs License Law dors not apply On An owner or Required Inspections
propeny who builds or improve mcrcon,and who does such work himself er through his
own emplmyers,provided thatsueh improvements em not intended oroRered forsala IL
however,the Wilding or improvement is sold within one ys.of rompletion,the uwncr-
builder will new the burden of proving that he did not Wild or improve for purpose of
sale.).
❑I,as owner of on,propcny.am exclusively contracting with licensed Con®mors m
consumer the project(Sea 7060,Business and Professions Cori The Contractor's Li. .
cane taw docs not apply to an owner of progeny who build;or improve thereon,And,
who contracts for such projects with a ccmrutoKs)licensed purswm in the Contractors
License Law.
❑1 am exempt under Sec. ,B k P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affium under penalty of perjury one of Be following declarations:
t. I haw and will maintain a CenlRam of Conscnuo self-insum for WorkcrsCompen-
ration.as provided for by Section 3700 of one labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,es required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
W--oroces Compensation Iwnna Carries and Policy number m:
tk``A1y
Y gil. lna(:aA w�wi PolicyNo.i�uL6S0\0`gOt00 0
`"`1111���� CERDRCATEOFEXEMPDONFROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not becomplemd if me permit is panne hundred dollars(SIM)
or It..)
I mildly mat in me performance of Be work for which this permit is issued.1 shall not
employ any person in any manner An a in become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Com;mention provisions of tM Ia Wr Code,you most
,J O foMwim comply wire such premain.or An.permit shall he deemed cooked.
Z o CONSTRUCTION LENDING AGENCY
'T+ Ihemhy AM.Wt Nem iaeronswetion lending agency for Be pedinnnamoc of
Qi r>-r the work for which this permit is iuucd(Sec.3097,Civ.C.)
W A Lendcrs Name
6. Lender's Address
U Q I certify that 1 bars mad this application and sate that tie ebuw information is
(y r comem I agree to comply with all city And county oNinenas and sum laws mlating In
U building construction,And hereby authmrim representatives of this city to enter upon me
r W above-mentioned properly for inspection purposes.
gy (We)Agree ro save,indemnify And keep harmless Ne City of Cupertino against
co) liabilities.judgment,costs and expenses which may in anyway accro,against said City �^
U Z in consequence of the granting of this permit. J
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sOUR�RAppli ONgil $^
4Tfb`(`5 '23'o`1 Re-roofs
Signature or App icaHAZAR ter Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will thea Cu,aCm or rumor Wal Co e.Chapter
or handle dlo hanNoun material
u dc.Sed io the Copcnino Municipal Code.Chapter 9.12,and U¢Health And Safety
Chat Oyer
zssu(aI7 / All roofs shall be inspected prior to an roofing material beim
❑Yes I7 Na P P � Y g g installed.
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haniu us air conmmim, v defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
El Y. Nu
Ihave&Saread thchz.Sectio 25!105. m33=it 5514.1 under Comiandpter 95ofthe Wildinr.
g �A ' 23
ria mil Cu SafetyCade,SccdonsaritI1oryoand2553s.1tomAilLhoOCCthcWilding K -0
docs not arcnJy M1aw a tenane mat it u my rc;ponsiM1ilily w nouly the i xupant of Nc -
mquimmc hi est (pdormissuance ofaCcrdnegc�IOccuPancy. Si'nature of Applicant r Date
m � g 23 O4 All roof coverings to be Class "B"or better
Ow Tor aumorirsd agent Dam
Community Development
10300 Torre Avenue
'/' Cupertino CA 95014
t4
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMIT # O C* O lg.a
OWNER'S NAME: mosoS vjlw% PHONE #L.to8 zj -o3'ao
GENERAL CONTRACTOR: iFb r Sao aoa s FAX #
I am not using any subcontractors: R-SS- o V
Signa 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 _ v r e a4 oNs210
Septic Tank
Sheet Metal
Sheet Rock
Tile
�� � w..� fs•23.04
Owner/Contrac ignature Date
Community Development Department
y Building Division
if City of Cupertino
]0300 Torre Avenue
' Telephone: (408)777-3228
CITY OF
IS U P E IST I 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: (moo se-5 A wS r.
Job Site Address: 20'T9 CridC.�+ 4t it RA .
Roofing Company Name: DVA- S FaSuaS EnbFIN4Q,
A plicanfs Signature: Cia�M !!= . Date: $
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO ` Z
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# 3 4?_ 3 So I $ I
Date:
Building Address:
22880 GricKei- l-k; ll
Owner's Name: C t (� Phone#:
MOSGSt GUw�/� DE AN7.a.0AV-sR C �lbg � Z� fr — o330
Contractor: Phone#: License#: p
FO C a CA ONS o0 -olza ~� ZIOo
Contact: Phone#: Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt ShinglesAsphalt Shingles
ElWood Shakes ❑ Wood Shakes
❑ Wood Shinglest ❑ Wood Shingles
Other(Specify) rl�' —004 11 Other(Specify)
umber 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: p
�tr-..e ve, cow.w ob� roo-C t n.C}'o.�1 t�z" \ A c..9 l'�S�•'i'^ �8
Residential Commercial ❑
Fire Zone: Yes ❑ No Oy Confirmed with Planning Dept. if
there are any restrictions: lJ
Cost of Project: Type of Construction: Occupancy group:
r1 &_ n
6 CJVD G 'tom- eCtOe...T\s.�..
Qty. if
Applicablb Fee lD Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
f BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
6-7
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