04090259 ' CITY OF CUPERTINO
BUILDING DIVISION PERMIT GONTRACTORINFORMATION, t
BUI LDINGADDROS: ., PERMIT ND04090259
749'; FAT,T.F.MTRAR TM FINN FD
OWNER'S NAME: PERMIT ISSUE DATE
KIM MATA21CH OCT v 2001
NE:
SANITARYNO.. CONTROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lo,
O LICENSED CONTRACTOR'S IARATION Job Description
V C 1 Mrtby affirm that 1 am lianscd under vont of Chapter Y(commelNinB
b N on7 MB of Division 3ofNe Busirrx Professions Code.and my lieenscu
^�> n�fW ae ata erfer� .3q Lie.N -2 5 ROOF-T/O INSTALL FIRE FREE SLATE
j � Li Cless t
p Dam —2 ISG s G or Gsf d
ARCARCHITECTSS DE DEC N
W� laddvatissV. Ply h,l �yua p.blicmenw 9/22/04 PACIFIC COAST ROOFING PD BUS LIC
Licensed Prolessigotal
3OWNERBUItDER DECLARATION
1 hereby affirm Nal 1 em exempt from Ne Contractor's License Law for the
O o following mason.(Section
?831.5,Best.and Professions Code:Any city or county
K$ which mO.ocs a Permit us convect,alter,improve,demolish,or repair my structure
priorwiuiouincc,alwr uiresthcapplicant for such Permit o file a signed statement
dust W is licenmd pormant in the previsions of the Comranur's U..law(Chope,9 Sq.Ft. Floor Area Valuation
a�th (commencing with section 7")of Division 3 of the Business and Proressions Code)or
y $ that W is exempt therefrom and the basis for the alleged exemption.Any violation of 0
Section 7031.3 by any applicant for.permit subjcm the applicant to a civil Penalty of ApN Number Occupancy Type
not mom Nan five hundred dollars(5380).
❑Lssoww of the prcpenY•ar mY employm with wago azNeir tele compensation,
will do the work..ndth.auucmm is notintended or offered formic(Sec.v04d,Business Required Inspections
and Professions Code:The Comncmra License Law does act apply m an owner of q P
property who builds orimprons thereon,and whodons such work himself or through his
sun amployees,provided thatio ch improvements are not intended oroRered furoate.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1.as owner of ram property,am exclusively contracting with licensed contractors to
convent the pmject(Sec.7W,Business and Professions Cade:)The Contractors Li- _
cense law docs not apply to an owner of Property who Wilds or improves themun,and
who contracts for such projects with a con rector(s)licensed pursuant to the Connamora
Lkeess law.
❑I am emnspi under See .B&PC for Nis ressma
Owns, Dam
WORKER'S COMPENSATION DECLARATION
41 1 hereby affirm under penalty of perjury,one of the following declarations:
1 have and will maintain a Certifinm of Conant to self-insom for Worms'sComp rt-
sauan.as prcvidcd for by Section 3700 of Ne Latin,Code,for Ne perm ndmac of he
work for which this Permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,m required by Section
3700 of the labor Cade,for dm perfosmmce of Ne work for which this permit is issued.
My Workels Compensation Insurance canner and Policy number am:
C.41. Com ,T 6Ej2 adPolicif Fl FR
No.: i4�G X57
CERTIATE OFE 11MMON OM)t K2 —
COMPENSATIONINSURAN_CE,
(Thu section need not W complemd if the permit is forone hundred dollars(5100)
or lcu.)
I cerin that m the perf..an.of Ne wort for which Nis Perms is issued.L seal nut
.mploy any permn in any manner m as to become subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this Ccnificatc of Exemption,you should
Income subject to the Workers Compensation provisions of Ne fawn Code,you must
.,2 forthwith comply with such provisions or this permit shall W dccmed revalued.
ZO CONSTRUCTION LENDING AGENCY
i•. I hereby affirm that there is a convection lending agency for the Performance of
W> the work for which this permit Is issued(See 3097,Civ.C.)
CP3 A Lame Name
z fender's Address
U Q 1 certify that 1 have read this application and sum Nat the aW n information is
P corect.I agree to comply with all city and county ordinances and slate laws minting to
0U building convection,and hereby auNorin representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agme to save,indcami fy and keep harmless Ne City of Cupertino against
f' N liabilities,judgments.costs and expenses which may in my way seems against aid City
U in cummqucnce of the granting of this Pcrnit. /
.. APPLICA14T UNDERSTANDS AND WILL COMPLY WITdr ALL
NON-POINT Issued by: - Date
;�ignatmr
RC
S.
1-2S`� Re-roofs
RDOUS MATERIALS DISCLOSURE uor Dam Type of Roof
Will thc applicant or future building occupant store or handle hnardous material
fined by the Cupertino Municipal Code.LTapter 9.12,and the Health and Safety
,Seclios25332(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ®NaWill the applicant of furore Wilding occupant tax equipment or devils which If a roof is installed without first obtaining an inspection,I agree to remove
Invem mus air contaminants av defined by the Bay Arca Air Quality M.....cm all new materials for inspection.
ito?
0 Yes pJNa
I have mad the boardous materials requirements under Clopte,&95 or dre Califor.
ria Health&SafctyCodc,Sadom 25505.25533 and 25534.I urdcrvand lhuifdm Wilding
not eurmn0y havea mt.nmNat 1t u m near bility m notify the occupant of the f 1
sum e s n arxmetpdoriound emfaccmrcamorocapmcy. ignature Applicant ate
4—zH �y
owner wm,,i.d agent Date All roof coverings to be Class'B" or better
Community Development
3 't 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRE �e SSS: rQ PERMIT #�
OWNER'S NAME: 6 '�� N PHONEQC
GENERAL CONTRACTOR: 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
Septic Tank
Sheet Metal
Sheet Rock
I Tile
�� O ner/Contractor Signature �—� Date
Community Development Department
f '- Building Division
{ t ;, ' City of Cupertino
I
10300 Torre Avenue
CITY OF
(408) 777-3228
Fax: (408)777-3333
SUPEkTINO
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 complywiththe above stated policy on re-roofing.
m�r Y/
Homeowner's Na "c M I '/�r.u F C,, S c�
Job Site Address:
Roofing Company Name:
A p&canYs Signaturae J Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
' REROOF
�CUPEkTINO PERMIT APPLICATION FORM U
APN# b� Date:C( D_ Z ti
y -
Building Address: -t
gO CID
Owner's Name: Phone#:
'93 (- -72-11 - 19 2-3
Contra or: Phone #: License#:
P �21;57z
C c Ero
Contact: Phone#: Cupertino Business License#:
I Type of Roof Covering:
Existing: �a✓J Sh,�, Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles . . ❑ Asphalt Shingles
El' Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles `
❑ Other(Specify) Other(Specify) t e�er- Sj0.ie,
Number of existing coverings ❑ Provide I.C.B.O.Report#
.4@ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With Cu ertino's Tear Off Policy: ❑
Job Descriptiory:, i I f
Vx 1 e,cr -o� GncL t1s Ps- e, 4
Residential ® Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plannin Det. if
there are any rest tons: 1 I
Cost of Proj ` ype of Cons Occupancy 97
p:
Qty. if
Apphc,able Fee fD Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
— BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING