04080133 CITY OF CUPERTINO '� � 77 �' �'�'�
BUILDING DIVISION PERMIT Cath'.L'1'#ACTUI2INF'C} M�A'TION, .; .
BUILDING ADDRESS: PERMIT N0,
JACK MYERS CONSTRUCTION 04080133
OWNER' AM - PRRMIT ISSUE DATE
ONE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p Zo LICENSED CONTRACTOR'S DECLARATION Job
a V 1 hereby union that 1 am licensed under provisions of Chapter 9(commencing
< with Section]1111U)nfDivlsion3of the Husinmsand Prafcuiuns Co@,end my amounts 5 � imm�rmeanderreaL �i REROOF W/COMP.
jn i Licen¢ Lic.p
�~ Date Conumtor
Z! 2004
¢¢ ARCHITECTS DECLA TION AUG/"� u YY Lt
I nomination my plans shall be used in public recom s
Oyu
;ot Licensed Professional BUILDING
OWNER-BUILDERDECLARATION
F I hereby.(firm that 11. ucmpl s an the fessors Cas License Law for the
,]O following inamn. pand(Section](131.5,Business and Improve,
mordant,
Code:Any city s county
k m which its requires a Permit re cnnawcL s@s,ice fmw,h Permit t m repair any structure
poor to its lensed p,also lmn to the theapplicantfor suchPctur's icensle a e ned Law
that he ending wit PSection 70th)of Diviorm3the Commcmr'a License Law(Chapmr9 Sq.Ft. Floor Area Valuat on
rc�th 'at(cohe isci mfo it therefrom
and Us Division or c(N alleged ma and Profena.An,
Cade)or
Net on a exempt therefrom and the base for Ibj alleged emicsom o.Any violation of
Section 7031.5 by any applicant fora permit subjects the epplicenl m a civil penalty of 2W�.i�r.,..,1.
oat more Nan five hundred natio($300). - '3 6Ei°2`3 WtlYYerO O Occupancy Type
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work end Ne ewclum is not intended or offered for sale(Sec.70,14,Business
and Professions Code:The Convector's License law does not apply no an owner of Required Inspections
property,who bu ilds or improves thereon,and who does such work himself or through his
own employees,provided door such improvements are notintended oroffered forsale.If.
however,are building or improvement is said within one year mcompletion,the owner-
builder will have the burden of proving Nat he did tint build or improve for purpose of
sale.).
❑1,as owner of dm progeny.am asclusively contracting with licensed contractors to
common the project(Sec.7044,Business and Professions Cade:)The Contractor's U.
term law does not apply in an owner of factory,who Wilds or improves thereon.and,
who contracts for such projects with amonomania)llcenmd pursuant to the Convenor'
Lima.Law.
❑lamas pt undo Sec. B@PC far this recon
Owner 15em
W RKER'S COMPEN ON DECLARATION
by affirm under penalty o4 qury one of the fallowing declantiam:
Ih and will maintain a Ccniftcate of Cmuent to mlf-insure for Worker's Compete
-tion,as provid)d for M1y Section 3700 of the Labor Code,fm the performance of the
work for which this permit is lasted.
01 have and will maintain Worker's Compensation Insurance,as required by Section
3000 ofthe labor Calc,for the importance of Ne work(or which this permit is issued.
My Worker's Compensation Insurance candor and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(The maim need not W completed if the Permit is formic hundred dollars(SIM)
or less.) I
1 certify Nal in are performance of Ne work for which this Permit is issued.I shell not
employ any person in any mann ds W 6hE) tib l ba the Warkcn'Compensation
Laws of Califo .Dose
ApPlinnt
NOTICE TO ICA :1,after making t' console Eiemption,you should
became euhje Ne Worker's Cempecor previsions of the labor Cade,you must
Q 0 foMwiN co y with such pmvisinna or dpi permil shall be deemed invoked.
r CONSTRUCTION LENDING AGENCY
'rr I hereby affirm Our ft.is a construction lending agency for the Performance of
lYi 7 the work for which this Pnmit u stand(Sec.3097,Civ.C.)
4 Lender's Name
Q z Lender's Address
O Q I certify that 1 have mad this application and auk that Ne above Information is
lT. torten I agree to comply with all city and county ordinances and aide laws relaling to
0 building construction,and hereby suNarim representatives of this city to enter upon the
W Aiwa-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless dm City of Cupertino against
y
liabilities.judgments,costs and expenses which may in any way accrue against mid Cily
U Z in consequence of the granting of this permit.
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS, 3 �&o
e,<re
Re-roofs
Signature mApplicanuComrm70r Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupan loon.,handle havardous material
as denrcd by the Coconino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(')? - All roofs shall be'inspected prior to any roofing material being installed.
❑Yes Pa
Will the applicant or future building occupant um equipment ar dcvicm which If a roof is installed without first obtaining an inspection,I agree[o remove
mit limitations air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes �fNu
I have mad the hanrdausmateriaereyviinmants under Chapur6.95aftiw Calif., /� O
ria Health&Safely ocat.Sections 25505,25533 and 25534,I understand that if on Wilding
does nowu6hh
w a icnan4 Nat il' my responal iloy m notify the occupmt of Nc
requihem mus an issumcemraCertificatiofOccu ry. $i n tureofApplicant Date
Owns r aFcnt , All B of coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB AD2D•RES PERMIT #Q G/6�o 123
OWNER'S NAME: PHONE # Ocj�'
GENERAL CONTRACTOR: FAX # -50
I am not using any subconi- ors:_ ,r �(Y c,
Signature / Da
Please check applicable subcontracto d complete the f owin 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
Tile
f
J
caner/Contractor) afore D e
Community Development Department
Building Division
Ma City of Cupertino
re 10300 Torre Avenue
Telephone: (408)777-3228
OUPER,TINO
CITY OF 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:
Job Site Address: 2 6
Roofing Company Name: ///
A plicant's Signature: Date:
• Greg teel
Building Official
Revised 1/30/03 -
Printed on Recycled Paper
CITY OF CUPERTINO
00 REROOF 0 q oz 0/ 33
CUPERTINO PERMIT APPLICATION FORM
APN# Z d 2--2— Dater/ 0
Building Address:
Owner's NM/ Phone#:
Co ctor: Phone#: /�/j}� 76/ (�S License : 3 _ L ro
Cc6ACt Phone _/ Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt ShinglesAsphalt Shingles
13Wood Shakes ❑ Wood Shakes
KWood Shingles 13 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: SD
Residential 11 Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed w'th-Planning t. if
there restrictions:
Cost of Project: o 0 Type o Construction: cc andy gro r
Qty
AplilicAble Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY EnLrgy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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