04080244 CITY OF CUPERTINO " *mei aro '"�''`
BUILDING DIVISION PERMIT CONTRACTOR INK RMx 'TI<J>
BUILDING ADDRESS: - PERMITNO
STAAR DESIGN SERVICES 04080244
22571 SAN JUAN RD
OWNER'S NAME: PERMIT ISSUE DATE
SHOZO HADA 191 MESA ROAD nP.,/.27/2004
ONE: SANITARY NO. CONTROL NO.
(415) 663-1220
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
>✓Oo LICENSED CONTRACTOR'S DECLARATION Jo
1 hereby if,.Nde
Net 1 am licensed under provisions of Chopmr 9(commencing
a with Sm,f. 70M) fDivhihm3oftellimut a dProfessiuns Cado,andmylicenwis
<.� infullsy�pGr�tgand effect „ "41 S,�jS3 Fj REROOF W/ COMP.
n�O Da inn" — Common., (a0.
ARCHIT CPS DECLARATION s�r-34arZ NOV I - 2004
ya `run rad my plans shallbe used 3PV?0Ucnrda 1�1£�Jtlela�
«33 BUILDING
it or Licensed Professional S¢t7-kJl
y3 OWNER-BUILDER DECLARATION Cor ION
<Y I henry affirm Nat 1 1. exempt from the Convenor's License Law for the
foll0 0
which
other.Permit t 7fD L5,Business and improve,
d sines h,Code:Any air ityan or county
$ which requires n Permit on core,the aimG i t for
demolish, fix
any rrucmre
poor in issuance,also da,theapplicantouchraten OOlcasigned summent
mu he I.licensed Purwenuothe Provisions of Ne Corrector's 1iar.Law(Ch.ur,9 Sq.F[.Floor Area Valuation
urea (commencing with Section 7")of Dlvision3 of Ne Business and Professions Cnde)ur
�.- that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3*XNMftffiP.r0 0 OQGU
not more than five hundred dollars(5500).' ParaC y1YPe
❑I,as owner of the property,or my employees with wages as their sole compenssdon,
will do me work,and Mushroom.isnot intended or offered fistula(See.7044,Business
and Professions Cade:The Cotuacmrs License Law docs not apply to an owner of Required Inspections
property who builds or imphim
roves thereon,and who does such work selfor through his
own employee.provided that such improvements art not intended or offered for ale.IL
however,me building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving met he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Convector's U.
cense law docs not apply to an owner of property who builds or improves themon,and,
who contracts for such pecjects with a cenvanor(s)licensed pumuenuo tine Contractor'
License Law.
❑1 son exempt no.Sec. ,B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self i®um for Workers Compere
sell..,as provided for by Secure 3700 of the labor Code,for me performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Imurance,as required by Section
3700 of the Labor Code,forth.performance.(the work for which this Permit is issued,
y Workers Compensation Insurance cannot and Policy number am:
plesrwrieo
PoliryJKLeg f
r o%P—KfWEMPnON
AT10N 5 'S
-
INSURANCE
(This countered am Lccompleted Kure Permit it fortune hundred dollars(SIM)
or less.)
I certify that in to performance of me work for which this Permit is issued,l shall not
employ any persen in any manners,as in become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should
become subject t.the Worker's CumPemaoion provisions of me Labor Code,you must
.JO fth
orwith comply wire such provisions or this perecitahall M dmranked.
roked.
.Zr Y CONSTRUCTION LENDING AGENCY
[-a I hereby sates mm there is a construction lending agency for the Performance of
ai > me work for which this permit is issued(Sec.3097.Civ.C.)
Q Lender's Name t
.7 z Lender's Address
U Q 1 certifya mat 1 have read this application and stem mat the above information is
{f. H
comet,1 agree m comply with all city and county rwins of and stem laws miming to -
QU abovengconamd!pro and hereby auionprposeunmtivcs of this city mentorupon the
4Ll shove-memioncd property for imPection Purposes.
y (We)agree in save,indemnify and keep harmless the City of Cupertino against
y liabilities,judgments,costs and expenses which may in any way same against said City
U 7 in consequence of to Stenting of this Permit.
r7 S4t(2�
APPLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON-POINT Issued by: Date f
SOURCeREGULATIONS. Z
Re-roofs
Sign um of A,IicanUCo ser
HA RD SMATERIALSDISCLOSURE Type afRoof
Will me applicant or mum buildingoccuPantstom or handle leaysrdous material '
as defined by the Cupertino Municipal Code.ChaPmr 9.12.anti the Health and Ssfery '
ode.Section 25532(e)1
❑res N. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fumes building uccopanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants av defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Ju A -
Ihave&Safer thodc.So nusm5505 A53ocal.3.d255341cr Chapter
rstrod95tufdm Wilding /''.' �yy'r ,a /j
ria Healm&Safety Code,Secu.m 255(15.2533 anJ25534.Iu demtantl thuifthe Wilding
s
does not currently hove a mmam,met It is y msponsih'ray nodi the occupant of the
requireryenLl which..at be met pn:1nm colt am. Occupancy, Signature of Appli t Date
wnc oran%cdred agent AI oof coverings to be Class nBn or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
#UPER,TINO
Building Department
JO KESS: P IT #
22 54 S Jv a..� iLo ,a.� Cv - O 4 O $ O 2
OWNER'S N : S oZ-,o WAOA PHONE q
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
• Tile
Ownerfgbntractor Signature Date
Community Development Department
i Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY O
��I�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,with1997 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 Nam �?�
Job Site Address. /22
Roofing Company Name,/ =1ZJ tc �S
A plicanYs Signature: — Date: g 21� l04—
• Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
of
CUPERTINO PERMIT APPLICATION FORM
APN# � Z i� o �j� Date: /'►'U� • �� !�"'7
Building Address: V_0,0,0
e.1-T t J o
Owner's Name: I-{ O Phone#:
Naga 25� q-Ia-I
Contractor: Phone#: License #:
112TAA,f-- Ogs1&Pt4 W0-AJt4:-S 445 - 3 +Is- I $43 l3
Contact: Phone #: Cupertino Business License#:
'r=2E C-E JE✓trr 6e-tl - i5 49l'362(v
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
% Asphalt Shingles X Asphalt Shingles rr,- 3
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
� Number of existing coverings 6 N C ❑ Provide I.C.B.O.Report#
�W To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
�re-R-4_ o t=F- LX tsT't rt co S ryV L.t,S
Residential 21 Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed w'tlrPlanning D,ept^if
there ar y restrictions:
Cost r ject: /S� l Type of i Occ ancy grou .
Qty,tf
AiarplicAeJ 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