03080101 CITY OP CUPERTINO
BUILDING DIVISION PERMIT �11,CONTR[1CTOR INFORMA�TIO�N.
'
BUILDING ADDRESS: R-M YOUNG PERMITN003O8OZO1
s OWNER'S NAME: 14549 S. BASCOM AVE. PERMIT ISSUE DATE
T-TYT.F.TJ JAMES
NE` (408) 358-6977 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCH
i00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
m 1 hereby affirm IMI I am licemed under provisions of Chapter 9(commencing P
tial With Section 7B(M)uf Diision QSof NC Business and Professions Code,and
�Imy lm
;q<� in full fort and _ 7 y �6 J 3�` RERDIYF
? License cl 1 LIS.0 PINALEO
eQQ J RCI-S D N
f d� ay 1 undensanJ my plans shall W used tic rtrnrds�Oa(�J{v
a Licensed Pmfcssinnal SEP 10 2003
0,5 OWNER-BUILDER DECLARATION
I I hereby.(firm an I I.S.703 exempt from the Cosmos o License Law for IW
00 follwhnhrequing resaPeaittocnsconsumerand,After,
dcionsCWc:Anycilynreounty
cture BUILDING
5$ which requires a permit m aims t e apeq ni for
h Permit u m repair any strustatement prior to its cera ence,also nt to to the applicant for such permit m Glc License signed s hapten t
jt< thelhcencinnwJ pursuenn")or vivinaohhco,BusicessaPmficaw(Chspler9 Sq. Ft. Floor Area Valuation
el-$ (commencing with Section 7")or Division 3 a the Business and Profeuina Csstic)Or
i 5_ Nat he Is exempt therefrom and the basin far Ne a11e,Od exemption.Any violation of 3 7 5 3 3 0 2 3 0 0
Section 7031.3 by any applicant for a permit subjects the applicant to a civil pcmilty of APN'Number Occupancy Type
not more Nan five hundred dollars(SSW).
❑I.As owner of the progeny,or my employees with wages As their sale compensation,
will do the work,and the stmcturc is nut intended or offered forsal.(See.7 4 ,Business
end Professions Code:The Contractors License law does not apply to an owner of 307 - INSULAReq I90N d Inspections
praPetty who builds or improves thereon,and who does such work himself or through his
awn employees,provided that such improvements are not intended or offered for Asia.It. 601 - ROOF TEAR OFF
howevea the building or improvement is sold within one year of completion,the Owner. -
builder will have she burden of proving that he did not Wim or improve(or purpose of 602 - ROOF PLYWOOD NAIL
sale')' 603 - ROOF BATTENS
❑1,es owner of the property,am exclusively contracting with licensed conumetora to
construct the project(Sec.7044.Business and Professions Code:)The Contuacmr's Li. 604 - ROOF IN-PROGRESS
cecse law docs not apply to an owner o(prope ny who Wilds or improms Merton,and,
who contracts for such projects with o conisactor(s7 licensed p uxuanuo she Contractors
License Law.
I em exempt under Sec. ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby air,.under penalty of perjury oro of the(allowing ametur n omt -
1 have and will maintain a CeniGcate of Consent to Aelf-insure for Worker's Compere
section,a provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued. .
❑ 1 have and will maintain Worker's Compensation Insurance,a required by Section
J]BO of the labor Code.for the pcAormanec of the work for which this permit is issued,
My Worker's Compensation Insurance carrierand Policy number art:
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if she Itark is(mane hundred dmlarAlSIM)
or Iesa)
1 cenify that in the pcolu m ot.of the work for which this Permit is issued.I shell am
employs any manner as to hecop}gsupj�twpe Worl Compensation
Laws of y0ate
3' II'`'�aCC
AppQQlic a�n. I L
'NQT$E T APPLICANT: f. cr an this Cenificate of Exemption,you should
Wco c subject to the Worker's tape provisions or the labor cram.you must
.Jz forthwith comply with such provisions or this Pcanit shell W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(, Iherehy affirm that there is a mnssructina lending agency l'nr the ratfamance of
fk the..,it fur which this Knorit Is matted(Sce.3W7,Civ.C.)
W Lender's Name
M z Under's Address
V Q 1 ecnify that 1 have read this application end state IMI the above informed..is
W F torted.1 agree to comply with all city and county ordinances and sure laws rcla ing to -
OU building construction,and hereby aushortre representatives of this city to enter upon the
W above mentioned progeny for inspection purposes.
'
(We)agree m save,indemnify and keep harmless the city of Cup:nine against
aj liabilities,judgments,costs and expenses which may in any way accrue against said City
C.)z in mrtaequence of the gmnting of this permit.
^ APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:914 Date
SOU RE L 0
3 Re-roofs
Signatureo Applican nlsumr etc
AZARDO M TERIALS DISCLOSU Type of Roof
Will the applicant or future ding Occupant store or handle havamous material
a defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,section 25572(a)?
❑Yes 'RNu All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
out Mrardaus air contaminants As dcfned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
Ihow&Sdre t the MaaNnusmauriolsrtqulmments 4,;c Cha.dffi5ofthc Calmar, ( 0
nix Health&SilctyGMc,Sccdons 233(13.2337Jwd233J4.l undcrsmnd thuifthc building
rima sol curtcmly baso a tenant.that it is my rcapouihility to nndfy IM occupant nl dM ��
rtyuimmc whi mu M mel Poor m issuance of a CcNGc of c�p�n=y. Igna--d tur00I AppliC6 z? Date
3 0 All.roof coverings to-be Class "B" or better
0 ser or atiubtared agcnl U Data
�- yr
Community Development Department
f
Building Division
FCity of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
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 *tb the above stated policy on re-roofing.
Homeowner's Name:
Job Site Address: /Q/r r Y
Roofing Company Name: •wl r 0tiw s Rio i niR
A pficant's Signature: (/Y Date: 195 /1,
4i 3
Greg teel
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO 03 6s aw o o�
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# r G Z Date: /
Building Address:
I T03 P1?wV6Verq1A5fAV Rakje4a fli oxi ALL
Owner's Name: / ,_ / Phone#:
Contractor: /EI171� y- Phone#: License#:
�vl- �J4N tcuuG-i.v gt)VI359`6G ,77 7 '7 (o$3b�
Contact: Phone#: Cupertino Business License#:
goV-373— icp�
Type of Roof Covering:
Existing: Proposed:
m Built-Up Roof Ca Built-Up roof 1�
❑ Asphalt Shingles IR Asphalt Shingles 13 Q
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) He 7' IM n r or Ir ❑ 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:?
J a�� I L I�O� H.,. G L 0 C f� Y'LAS� N
Residential a Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plan '__ j1 eyt. if
there are anr actions: \
Cost of Project: a� Type of Construc4ow.--1 Occupancy oup:
Qty. if
A li b e Fee IDFee 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
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