03050059 (2) CITY OF CUPERTINO
BUILDING DIVISION PERT CONTRAC 'UR T�1V' 'U'itMATTU "
MI
BUILDING ADDRESS: SIMON SAYS ROOFING PBRMIT"°03050059
1Q1 F.T,MSPC)RT) DR
s OW NEWS NAME: 3866 REXWOOD CT �" n7l3/2003
ICHARD SILVERMAN
"E: (408) 531-9700 SANITARY NO. CONTROL NO,
ARCHOECDENGINEER: BUILDING PERMIT INFO
BLDG 1
ELECT l PLUMB MECN
>j or
OE LICENSED CONTRACTOR'S DECLARATION - Job D C O
j bt 1 Wreby affirm Net 1 am licensed under provisions,or Chapmr 9(commencing
with Section 70(p)ofDivi hm 3.f Jen Businus W Profese-s Code."MY licens is
5pp in full Toms ane e@ Z Data '17 7 L�f�, REROOI-,� may, \
(d Z Lictnm 1 s C Lk.N
As hall h use DECLARATION
1 undcrwnd my plans shall be used as public records
7
3 Licensed Professional
OWNER-BUILDER DECLARATION r"-
0 0 I Wmso .(firm on I sm
exempt from the Cssion Co e:A License Law for tbe
g a O following resort.(Section 703 nsum Business np PmktiOns Cale:Any city Or county
gaff which tequims a pamim to acquires
alma i applicant for su demWsh,ore&sig any urucmm
lw pdortuisiensedpalmmqulru tbeisioof for such permit mfdeuigadmtement
F O Mahe in licensed hSmlintmdmpfDivWon3OmCanuacmistiPmfedw(Clupter9 Sq.Ft.Floor Area $1gY�blgtion
$
(camin n7 of tiro Businw Wma.M ACode)or
r Seco i031.s ny em epplicmt er apepermits subjects thhe e aPpIbmAL m a ctvlltiPenalty Of 3 W6I81itMer0 0 Occupancy e
out mare[ban few hundred dollars(M). P y •TJy P
❑I,nownsrofthepropeny,army employees with wgustbeir sok cornperrstion,
will do the wort,and dissensions u not intended or offered forsale(Sm.7044.Business dIDS eCt10DS
and Pmtrssiorm Cam:The Conastofs Licen Law dee me apply m an.war Of 307 — INSULA 11 VN P
progeny who buildeorimprovs Hereon,and who doessOchworthimselfar Wouglr hu
ownemployeu,provided that such impmvemenu atenot Intended Or offred(male.If. 601 — ROOF TEAR OFF
however.die Wilding or impmvemmt is sold within i m year of completion,die ovmtr-
WilderwiBNwHaburdenof proving that bedid an[Wild orimprowfar Purpose Of 602 - ROOF PLYWOOD NAIL
"to.). 603 - ROOF BATTENS
01."Owner of the property,am soclusively contracting with licensed conusmn in 604 - ROOF IN-PROGRESS
construe the pri(Bea.70th.Business and Prorsuons Code:)The CamnauoYs V-
conuLaw duesnot apply toanmanner ofpropenywho Wilds or impnews Hereon,and,
who contracts far such projects with a communist licensed Punumt in He Contncme.
Liens Law.
❑IsmaxeeptanderSee ,B@PCfa W3MsaM
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby same under penalty of perjury ane or the following dalas0ons:
1 haw and will maintain a Certificate of Consent to self-laude for Worker's Creation.
77.100
ion.es,provided fm by Section 7700 of the LAW,Cade,for Um petformaece of the
rk for which this Permit is Issued.
I haw and will maintain WorkeYs Compensation Iris pane,an required by Section
of the Lbor Cade,for the penarmance of Ne work for which His permit is isued.
yWorker's rope tion IMurarme nnisr roti Polity number are:
mier >� liry No.ns-5-0
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need tree eccompli m l true,permit Ismrone hundred dollars($HaE
In less)
1 certify that in He performmce of Jen work for which His Permit is issued.I shall not
employ any person in my manuer an as m become object to die Wormis'Cmmpens0on
Laws of Califomla,Dem
Applicant
NOTICE TO APPLICANT:If.after making that Certificate of assertion,You should
become object to He Worker's Compensation provWons of He taw Code,you most
,J Q (oMwith comply with such previsions or this permitshall be deemed ammked.
z-r ti CONSTRUCTION LENDING AGENCY
[.w IWreby affirm that diem is a construction lending agency for He performance of
a> the wort fur which this permit Is Wuetl(Sec.7097,Civ,C.)
W� InndeM1 Namc
z, lender's Address
V 0 I certify that I low read JJs application and rote that the Aon information B
Iy COMMM,I agree as comply with W city and county ordinance;ami some sew reining as
0 Wilding construction,and hereby oHotis represnatiws of this city to enter upon He
{iI Move-mentioned Property for ispeeuon Pulp=&
(We)agree in sew,indemnify W kap harmleu the City of Cupertino agunst
rrA lubilitia.judgmens.eots and expenses which may in anyway aecoe against Mid City /
() in APPLICANTSOf um UN UNDERSTANDS Ami Or ND LL WIL PLY WITH ALL NON-PO Issued by: Date
SOURCE REGULATIONS.
�3 Re-roofs
Signature of ApplicannConum dr Date
HAZARDOUS MATERIALt DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant mom or hurdle hMsrdous material
ldmde0aed by He Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
de.Seeders 335724)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya 0
Will He applicant or return Wilding Occupant use equipment at devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
It basrdous air conumin"s s defined by tad Bay Asa Air Quality Managcmem all new materials for inspection.
urict7 —�//
❑Yes B"-
IhawreadtheWsatdosmsmnakrequiremcnsunmr Ll.mdthUifdieWilding �( '
macurSuety Code.SaJamhat it *MyMOMhili,Iu milily thuifiheal Or Me \_7/K_- �'1`aJ--"y �//17-
not currently Mw a sonans Net h s my ruponsihllhy m notify Jen ixcupane of Ne
uimmcns khmu tpriorm' a(aCouricamofocc ry. Signature ofApplican Date
S 13 All roof coverings to be Class"B"or better
ner a authonsd 9994 Oslo I
Community Development Department
Building Division
City of Cupertino
t 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
CUPE(�T1N0
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 Y4" 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.
Homeowners Name:
Job Site Address: //a 3
Roofing Company Name: innAV
A plicanYs Signature: • Date: l�03
\�1/�61ADLXl
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# 2 B Date: -5 //310_5Building Address://0 3 � J l
Owner's Name: n Phone#:
6?9/ -O/ Z- Z,
Contractor: Phone It: License#:700 7P"�9 p
3l- 9 O
Contact: Phone#: 67M, Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles l k Asphalt Shingles
�C Wood Shakes ❑ Wood Shakes
d Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ElProvide I.C.B.O.Report#
T`uTo be Removed ❑ Provide Mfgr. Installation Specs.
• I Have Read, Understand and Will Comply With Cupertino'_§ Tear Off Policy:
Job Description:7,_p
'
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of��roject. Type of Construction: Occupancy group:
'3 ZOO • Ob
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