05010166 CITY OF CUPERTINO K s,.y',of ' "�"��' ` '`" °'
BUILDING DIVISION PERMIT COiTRAC'TORINF'OI2MATION
BUILDINGADDRESS: FOUR SEASONS ROOFING PERMITN05010166
FA.
OWNER'S NAME: PERMIT ISSUE DATE
THERESA M. SIEGFRIED 64S HORNING ST V
ONE: SANITARY NO. CONTROL NO.
(408) 278-0330
ARCHf1ECTlENGTNEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
Y00 LICENSED CONTRACTOR'S DECLARATION O O O O
u I homey affirm test 1 am licensed under previsions of Chapter 9(commencing Job-Description
with Section 7")of Division 3 of me Business and Professions Code,and my license u 4reads
zn
to fu'
-39 t/7��0 REROOF W/ COMP. N
License CI Lie.N i,
,n F Date Contracmr �
ARCHITF.LTSDECLA ATION
�iI understand my plans shall be need u public meet& "A Lrko��
DyU MA
'C t; Licensed Pmfeessional
3 OWNER-BUILDER DECLARATION T�
C 0 ng cmhy.(Erse on 1 am exempt Ifum dr Contractor's License law for the 'I )/II I�A
S po O following mean.(Section t I L5,xempt from
he Contractor's
Code: n cit or county
I ll✓^sy U 1ul IgICs 1/
which sequins a Permit a,construct.alter,improve,demolish,or repair any auucmre f
Fi< pdwwi.lssuwcc,alwtrquiresdcapplimiforauchpermitiorileasignedwmmcns
FFxe thathcislicensedpursuanttotheprovisionsoftheCommenrilienxlaw(Charter9 Sq.Ft. Floor Area Valuation
°f 5 S (commes exam idt 5ereirom and of D osis for
of alleged
sets wd Professions CWe)of
��� that he u exmpt therefrom and de bust for the alleged caemption Any violation of
Section 7031.5 by arty applicant far a permit subjecu the applicant in a civil penalty of
Type-
me,mom man five handled dollars(Ssoo). arts 0 Occupancy Type
El 1,as..,of me property,army employees with wage as their wle compensation,
will dome mark,and the Macau.Is nut intended mmffmcd for ask(Sec.704a,Ban..
and Professions Cox:The Cmumeme,License law don not apply m an owner of Required Inspections
property who Wildsarimproves thons,andwho doessuch work himmlforthrough his
own employees.provided that such improvements are notimmnded oro@red forsaln IL
however.the building or improvement is sold within one,year of completion,the Owner.
Wilder will have the burden of proving Wt he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed conlrxmn in
construct the project(Sec 7014,Businass and Profusions Code:)The Comoseu's Li.
cense Law does not apply to an owner of property who Wilds or improve themnn,Md.
who contracts for such projects with a conmacmr(a)licensed pursuant to the Comracmfs
License Law.
❑Iamexemptunxr Sec ,B&PCforthismaon
Owner Dam
73C73WORKERS COMPENSATIONDECIA TION
I hemby affirm under penalty of perjury arc of the following declaration:
M
Ihaveand will maintain aCeAEcateofConsenuaself-insumfor WorthehCompen-
don,as pmvixd for by Section 3TOS of the labor Code.for me performance of me
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance.as required by Section
of me Labor Code,for the performance of lie work for which this permit is issued.
y Worko' ompenadon Insurance carrier and Policy numberrtier: Ot"Lraslq_Ot. Polity No.: W C'cxro/o Y / V C!G j 6
G.fERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Ia�4u.
usmitm reed not W cmnpleed ifthe permit is reborn hundred dollars($1011)
car less.)
I cenify that in the perionalu ec of the work for which this Permit is issued.l shall not
employ any Pawn in any manner mss at becomesubjeei to the Work<r'Compenandon
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ccnincae of Exemption.you should
keman whject m the Wor,eri Compensation previsions of me Labor Clue,you most
.,O forthwith comply with such provision or this permit shall be dame,revalued.
zy CONSTRUCTION LENDING AGENCY
(-+� Ihemby.M.thin mem iso construction rrdingagened Jar the arfarmumea of
!Yi > tie work for which this permit is issued(Sac.3097,Co,C.)
�W A Undels Name
= z Lender'sAddmss
U Q 1 certify Nat 1 have mad this Milken..and We mat me show information is
D.P correct-1 agree to comply with all city and county ordinances and stag laws miming he
0 U .1mve-g cottoned ioc and hereby wthorim mosses, tiws of that city th enar upon me
ahove-mconsned propend for inspection purposes
F a (We)agree in save,indemnify and keep harmless the City of Cupertino against
i,l liabilities,judgmcn.,cos.and capcosn which may in any way accrue against said City
U Z, inconsequence,of a mi il.APPL
.-� SOURICA EOULATIO N D LL COMPLY WITH ALL NON-POINT Issued by: Date _ Z •U
Re-roofs
Sign of APPlicanUCon Dmc
HA2A ATERIALS DISCLOSURE Type of Roof
Will the applicant or uture Wilding Occupant store or bandk havual material
as&lined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Dyes 532(4)? No All roofs shall be inspected prior to any roofing material being installed.
Will tM applicant or future Wilding occupam use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvardnos air comemimmis as darned by the Bay Atha Ail Quality Mwit,cmcnt all new materials for inspection.
District?
O Yes /SMR
(have mad me haraNnu" smamriab rtyuimmcn.under Chap¢r6.95 of me Califoo-
nia Hcalth&SafctyCox,Scctiom75505,25533md25534.lun&rsm ifde Wilding / �(�
does not conentl wa t it¢my msponsibllity m rattly the occupant of the �1.�
equirement- le moctprtru)uhuanttofa Cenifeate of apauy.
Signature o Applicant Date
Owncrafauthofircdegcn Dam Allo 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 ADDRESS: PERMIT #
oY9 o sem / S • 63-0/ 0/ 6 G
OWNER'S NAME: arcSca STM-Y-F'-;eCf IPHONE # 278-0 0
GENERAL CONTRACTOR: ea o S -,q FAX # 2.;-?
I am not using any subcontractors: / - 8 6.'
Signa Date
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Ah Linoleum/ Wood
low Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing Fou Sem so,,s aFi `t"7�lOo
Septic Tank
Sheet Metal
Sheet Rock
Tile
qx�
Owner/ContSignature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY Of Fax: (408)777-3333
UPEkTINO
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: er4Ccc M i e4 f'r i
Job Site Address: /O 9 9 AJ o i-M4 a,a/ S ;
Roofing Company Name: Four Seed on S P_ooFl a C
A plicant's Signature: Date: 1- a -o r
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO o 6 6
alayoFREROOFCUPINO PERMIT APPLICATION FORM
APN# O6� Date: . ?L-7 - o
Building Address: 17 S
Owner's Name: Phone #-
2-? fr—0-?,g 0
:2-? fr-0330
Contractor: Phone #: License#:
Four Se-o.so,,s Roo-Fe'n
Contact: Pho #: �-�& -033 O Cupertino Business License#:
Al-�roclo Ca2areS ne
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ,1P Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
?® Other(Specify) GAL S N A 1LS— ❑ 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: f II
Tho cel S(..al`ta. l t i.%srn4 30# �t �} I ci 1�1 CAF Gr, .J CA.,qc . CoM�
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Det. if
there are anrestrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
, 000 , g-F-06 f
Qty. if
Applicable 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