03070202CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
-ONTRACT,OI2INFORMATION
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BUILDING ADDRESS:
L1101 I MVNTTQnN All
PERMIT NO0 3 0 7 0 2 0 2
OWNER'S AMC.N
PERMITISSUEDATE
ONE:
SANITARY N0. CONTROL NO.
ARCHTTECTlENGINCER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hcmM1y afOrm Ih fam5ed under oro: 'Ina rrchapler 9 (ermmenting
wish Scni n) 7nf Divixi fthc Busincu an fc�asb2m,Cndc,endm license is
Lice cepa a
RFrROOF
License 4 Lie. N _ C.�
Date contra -+ E
CI'S DF L TION
I NTRACTOR: REAL-T INSPE �O�N a§ REPAIR SERVICES
CRE
A
n crsS off am dull M cd as t tic round
O
AUG �/
FI 1 8 2003
Iriccnsed Pm cwanal
BUILDER DECLARATION
Oat
I hereby .(firm that 1 the Contractor's License Law for the
I wo Immne
following 1. s an m
(totem 703 1.5, Business me Pmfde oli Codc: Any tiny ar county
-
wires a permit reconstructalmc improve,h parerepair
g
Sq. Ft, Floor Area
'
YI (Valup�ippp00'
gany dtatement
permits
prior m ie issuance, also requires the applicant for such permit m io a signed statemcm
prior its issuance,
that Law (Chapter
purction7 h) pmvivisio of the Conwmessan
mencccmcd
r orke)9
(commencing Section the Prue lation of
exempt
and the basis f c
that is li and the beer for the Any lineation of
alleged on. Any
ds
3 MN802il�ed O O
Occupancy Type
P Y YP
Section pliant to
by any applicant fore permit rohjects the applicant to a civil penally of
io 31.5 b any applicant th the
- -
not more then frvc hundred dalton (S500).'
than
❑ L u owntr the property, with wag. u thei(Se atlon,
cW,
Required Inspections
will Pr the work end n,my Outou tea
u
. mounted. Business
awnurt isnot Contractor's Lice
far Ile (Sec. inaa,Owner
Professions Codc: The law does
so� aw it not apply to an owner of
and e: of
305 - FRAME
stheread, and
property who builds or improves thereon, and who doca.uch work himself or through his
own employes, provided that such improvements we not intended or offered for sale. If,
307 — INSULATION
however, the building or improvement is add within one year of completion, tht evoro-
builder will haw the burden of proving that he did not baud or improve (or purpoe of
601 — ROOF TEAR OFF
sale.).
602 - ROOF PLYWOOD NAIL.
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
conswm the projce,(so.)o44. Business and Professiors Cade:) The Contractor's Li.
603 — ROOF BATTENS
case law Goes not apply toanowner ofpropemywho buREaorimproseethemon,and .
604 - ROOF IN-PROGRESS
who cumbrous for such projects with a contractor(s) licensed porauanS no the Contractors
License Lew.
❑lam exempt under Sec. B S P C for rcuon
Owner Dam
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ccnifcam or Consent to Self-insum for Worker's Compen-
a.tian. as provided for by Section 3700 of dm labor Code, for the perfmmence, of the
work for which this pconit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Chile, for the perfmo�rrho a of Neppo[[�� for which his pemnit I. Issued
My Workers Comparrod nInsunnce2rrlp�pdYNfey murder wo:
— Policy No.: _
CERTIFICATE OFEKEMPION FROM WORKERS'
COMPENSATION INSURANCE
mob section .,door hccompl"cd if the (omit is fm mm hundpad dollen (91018
ter loss.)
1 certify Nm o the perfmmanu of the work for whit Ihr Per h is issued Fret
cmployany Pcra inany Ir beer ata awkin
Lawn of Californl�ak Z
Ap Item
N 1 O APPLICANT: 1[ afmr making his Coffcate or Exemption, you ahrmd
be .ubjea m rhe Warkera Compcuetion provisions of the tabor Codc, you most
forthwith comply with such provision or this permit hat] be deemed mvoked.
CONSTRUCTION LENDING AGENCY
1 herchy a?rid that Nen is a commucunn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
lender's Name
Lender's Aedrou
I comfy that 1 have read this application and sure that She show infonnatiun ie
correct. 1 agree to comply with all city and county ordinances and state laws palating to
homeyauthorisrepresematives of this city to enter upon the
buildingconstruction,property
ahrve`
fin
(We)a agree to saw,
(We) egmc to cost, indemnify and kith harmless the City of
emnify an keep turbines
V
against id Ctagainst
which may In any way accmc against rid City
judgments, gran endOf
in conseq or the granting permit. 4
this Pe
A
APPLICANT SA
APPLICANT UNDERSTANDS AND WILL COMPLY WITT ALL NON-POINT
Issued by: Date
SOURCE RE A S.
Re-roofs
Type of Roof
SrOtcol'ApplicanUCceftractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ur future building occupant store or handle hazardous materiae
u defined by the Cupertino Municipal Codc. Chapter 9.12, and the dealt, and Safety
ode. Section 23532(a)?
All roofs shall be inspected to any roofing material being installed.
p vc+
prior
If a roof, is installed without first obtaining an inspection, I agree to remove
Will the applicant or road. building occupant um equipment or devices which
11 hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
atrld)
❑Yes '�Nir
Ihave mad the hmaNuusmamNa,25533 d2553.ItoCh.pter dratifthe Caldin;
nitsHn-ic-ieudyuve-ucown,25505,25573 esti 25534.1undersmnJ th........r
arae nm cumemly how a nenent, Nm it ie my resgsnsihilip m nnfly the ngcupenn of Nc
rcyui`mcn hlcg,�stbcmctpm. No. erf.camfl caang
�ignatureofApplicant Date
••G/,
All roof coverings to be Class "B" or better
ter
ter aunhorived agent Dam
�CI OF
UPER,TINO
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
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 olicy on re -roofing.
Homeowner's Name: f�1_i1": / �� /
Job Site Address: /(5 Z I I �f l S O 1� 0 F__ (� ll
Roofing Company Name: KE,4 L_ Z Std CS
A plicant's Signature: '2 el Date: /a 3
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
` &CITO
CUPEkTINO
•
CITY OF CUPERTINO
PERMIT APPLICATION FORM
U� C> 7 �Iov?—
APN # 3 1 l0 2
Date:
-SOL(
Energy
7&5 �
Building Address:
Seismic Fee Res
0 o2 AJ C -
BSEISMICOM
Owner's Name:
(�P.t—&1,( N 1
Phone #:
TC -
Contractor:
Phone #: •
License #:
-T acs aNM -
1}1 P, Svcs 9 96-Z3 V 9
513 20a
Contact:
Phone #:
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
Cl Built -Up roof
❑ Asphalt Shingles
Asphalt Shingles
Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings 1
❑ Provide I.C.B.O. Report #
XTo be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply
With Cti ertino's Tear Off Policy: ❑
Job Description:
RF o0E EXISTI /Z?_
II CSX3D' E( - D F_A-2%L
Residential ommercial ❑
Fire Zone: Yes ❑ No
Confirmed with Planning De t. if
there are any restr' ns:
Cost of Project:
ns Hatt' n: Occupancy gr
/0 OCX>
Qty. if
Anolicak(lo,-)v Fee ID
Fee Desrrintinn
Fee Gmun
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
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