03010201 CITY OF CUPERTINO •'
yLDINGAdlvlslON PERMIT CONTRACTOR INFORMATION W'
Bw1DiNGADDRESS: DPR CONSTRUCTION INC PERMIT NO.
10950 N TANTAU AV 03010201
ERS NAME: 1450 VETERANS BLV APPLICATION SUB DATE
-, iAISER HOSPITALS 01/30/2003
PHONE: (650) 474-1450 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
a OW ffirm that I Am licensed under 1 hereby apnwi,io..of Chaptero
9(...coca,
Mrs Section 7000)of Division 3.f the Busirmax and Professions Cale,sod my It..is
in fall force and effect. REROOF
Z O'g License Class I.i,.M
ozF, Date /-7o-oz LicI or `p/R tats.-n.;n. REMOVE EXISTING ROOF, REPLACE WITH SINGLE PLY
£ ARCHITECT'S DECLARATION
� y� londcrsund lanRC beuscd DECLARATION
THERRO PLASTIC MEMBRANK
by LL LICC113Cd PnIfCSGnnal ��
S
OWNER-BUILDER DECLARATION
pp u<I 1 hereby affirm Thal I em exempt from Ne Contractors License law for bbe
G O following naso .secheun]f131.5.Business and Pmfcxsinns ClNc:Any city nr auumy
a k$9 which mquires A permit m consumer,eller,improve.demolish.or rtPat,any svucti re
FZa, prior in its issuance.alsn"hims the applicant for such permit In file a signed statement
s< that he is Related pursuant tome previsions of she Contractor's License Law(Chapter 9 Sq. Ft.Floor Area Valuation
n€o (commencing with Section 7(1f11)of Division 3 of the Business and Professions Code)or
$ that he is exempt therefrom and the bases for fee alleged exemption.Any violation of
Seldom 7031.5 byanyapplicanl for a peneitmbples don a stated to A civil Penalty of APN Number $111000cy Type
not more Nen five hundred doll..(M).
❑I.as owner of the property,or my empleyacs with wages m their sole mmrensation,
will do the work.And Ne struclom is not intended or offered for sale(Sec.7045.Business 5±6090315 . 00
and Profusions Code:The Contractors License Law does not apply to an owner of Required Inspections
property,who buildsor improves themon,and who does such work himself orthmugh his
own employees,previded that such improvements arc not intended oroffered for sale.If. 305 — FRAME
however,the building or improvement is sold within enc year of completion,the owner.
builder will have me burden of proving that he did not build or improve for purpose of 307 - INSULATION
sale')' 601 - ROOF TEAR OFF
❑1,as owner of Ne Po pffl,am exclusively convecting with licensed contractors In 602 - ROOF PLYWOOD NAIL
construct Ne pmject(Sec.70.4,Business and Professions Code:)The Convector's Li.
cense law docs not apply to an owner of property who builds or improves Ihcreon,and 603 - ROOF BATTENS
who contracts for such projects with a contractor(s)licensed pursuant o the Cenuacmr'a'
License Law. 604 — ROOF IN-PROGRESS
1 am exempt under Sec. .B A P C for this reason
m Data
WORKER'S COMPENSATION DECLARATION
1 hereby elErm under Penally of perjury one of the following decimations:
El I have and will maintain a Certificate of Consent to self ensure for Worker's Compete
station,as provided for by Section That of the Labor Code,for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compcnsalion Insurance,m required by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurable carrier and Policy number am: l'
Cartier.401,1)04 ✓.✓IUs) Policy Nor:709:3 � 3
CERTIFICATE
WORKERS'
COMPENSATION INSURANCE AAN
a2COMPENSATION
(This section need not be completed if the Permit is for one hundred dollars(1100)
or fees.) rm
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner An atm become subject o the Worked' rope tin
Laws.(California Date
Applicant iiiil
NOTICE TO APPLICANT:If.efterm 'ng this CenbBt.req Ebben piton.you sFt ulJ'
Weems subject to the Workers ComPe tion pmvisiohihIahe VN Cedc"yndmerst
z0 forthwith comply with such previsions itahaBf�dccAn invoked. _
nth. CONSTRUCT10 ENDING AGENCY,
[-+ Iherehy aRrm Net Nerc isacon coon le_ndi��nppagencrlh performend
1:47 the work for which this Permit is issued CIv/C.I
C ` Uncles Name
z Landers Address
U 0 I certify fan 1 have read this application and sole that she show,mformalon is
Y. P correct.I agree to comply with all city and county ordinances and sum law.miming m
DU building commission,and hereby amhomn mpresenmtives of this city to enter upon the
{>J above mentioned property for inspection purposes.
1b (We)agree 1.save,indemnify And blit barmless th,City of Cupcnino against
y liabilities,judgments.costs and expenses which may in any way see=against said City
U Z to consequence of the granting of this Permit.
r.b APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU).ATIOtj9.' /�3O'O�
�-� �� Re-roofs
Signature of ApplicanuUmaracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building occupant store or handle harardour material
defined by the Cupertino Municipal Code,Chapter 9.12.and the Ilcalth and Safety
A,Section 25532(A)? All roofs shall be inspected prior to any roofing material being installed.❑Yes re
Will the applicant or future building occupant use equipment ser devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air coomminants as defncd by the Bay Arca Air Quality M...gemcnl all new materials for inspection.
District?
❑Yes No
1 have read the haaantoos materials mquirements tinder Chapter 6 95 of the Califon
re.Health A Safety Code,S=doux 255115,25533 and 25534.1 understood that tithe building p
does not currently have a tenant,that it is my responsibility n motif y the dccupom of the Cis_ �J �0
requiremcn.wpich mus` mctpr;er 'fousneeeracwhimstefaeupdney. Sig ature of Applicant Date
klCri••.✓AeT /-Al -O7 All roof coverings to be Class "B" or better
Owner or auNon,c]agent Doe
Community Development Department
Building Division
t
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
CU PEi�TI NO
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: WA-1 SER 4SZir*4 c
Job Site Address: l c?S-o X)• T_4,Lr1-R-u CvpFnn&)Q C4
Roofing Company Name: L'otlt T,Q u�Tie.r�
A plicanYs Signature: Date: /-,70-03
,s
\itJa61il1p(JCl
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper