04090221 CITY OF CUPERTINO •s 0V� g31
BUILDING DIVISION PERMIT �CO4NTRACT�OR INF,,.ORMATION .
BUILDING ADDRESS: COSMOS ROOFING PERMIT NO 04090221
020:2 130ITTLIMPR RD
OWNER'S NAME: PERMIT ISSUE DATE
%ONE:BORIS PRVZNRR 1901 Wn MIDDITRTELD WY SANITARY C OL N0.
(41 CS) 4 91-�;'l 73
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
_00 LICENSED CONTRACTOR'S DECLARATION lob Descrrrr{{{{{{sssa.�
F❑ I i..7 affirm that 1 am licensed under provisions of Chapter 9(commencing MAILED If—
iW�11 with Section 7gllyufDivision Softhc Bdsinc and Profcssiunv Codc.antlmyliccnse is Uu ////-(�t11tBpL`'llpry�_
�y inmlumue arta err 3 9 5 L/L1/ REROOF W/ COMP.
Z p DacPnse C gyq O Comrxbr
nFt ,V ARCHITECTS DECLARATION SEP a� 2��y
a Mu
I uersnd my plans shall bu e used P.M.mentos
i a.
u. Licensed Pmfcssianal 1I 11
3 OWNER-BUILDER DECLARATION D 11 11��®��
aq I hereby refire that 1 am exempt from Ne Contractor's License Law fur the U Iryl
p c following reason.(Secdun 703 1.5,Business and Pmfeexions Code:Any city or county
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m fill which require a permit m cnnstrat,eltea improve.demolish,m repair any nractioe
4 prior in its issuance.also requite the applicantfor such Permit to file a signed statement
xthat Wo
islicensedp..annth.prvisiovofOaCommutuhLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation
mp (commencing with Section 7Ba0)of Division 3 of the Business and Profe.iom Code)or
that he H exempt tMmfrom and the basis for the alleged exemption.Any violation of
S.cd.7031.5 by attyapplicant for.permit subjects the applicant to a civil penalty of 3ftt00 Occupancy Type
not mote Nan five hundred dollars(S5W).
O 1,a owner of the property.or my employees with wages as their sole compensation,
will do the work and the structure is not intended oraRered far sale(Scc.9814.Business '
and Profound Code:The Contractor's License Law does,not apply to an owner of Required Inspections
progeny who builds orimprows thereon,and who does such work himself or through his
own employes,pmvikel that such imprasemenu m not imended oro@rail for sale.If,
howeveq the building err impmvsment is sold within are yearof completion,the owner.
Wilder will haw the burden of proving that M did not Wild or improve far purpose of
sale.).
❑has mvar of the progeny.am exclusively eonuaedr,with licensed rna..to
construct to project(Sec.7064.Business and Profeand.Code:l,The Contractor's Li
cense Taw does not apply in an owner of property who Wilds or improves daemon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors
License law.
❑ 1 am exempt under Sec. .8&P C for fair recon
owner Dar
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Or following decaratimss:
lot I tine and will maintain a Cendparrte of Covent to self-insure for WorkeriCompen-
sation,as provided for by Section 3700 of the tabor Code,for the perfitmaam of tW
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as,required by Section
M or the tabor Code.for she performance of the work for which this permit is issued. '
y Workers Comppeeropum.Insurance citrin.,and Policy moork,am:
Cartier: S- T Policy No.: 2I_C)Ll.11L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if the permit is formic hundred dollars(Slip)
or less.)
1 certify Nat in Ne perfmrmunce of the..,it for which this permit is issued.I shall not
employ any person in any manner sit as to Ucromc subject to the Workers''Campcmation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you mow
.,O faMwith comply with such Provisions or Nis Permit shall W daro
rned oked.
Z CONSBUCTION LENDING AGENCY
F" I hereby affirm Nat then is a construction lending agency lir the Performance of
M the work fin,which this permit is issued(Sec.3097,Civ.C.)
tl]0 Lender's Name
Z Lender's Addreas
U O 1 certify that I have read this application and state that the above information is
^� cortex 1 agree to comply with all city and county ordinances and stmt laws relating to
�U building constructor,and hereby euphoria,mpresen0tive or this city to enter drain Ne
ahow-mentioned pmNrty for trajection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino againal
F' ferry liabilides,judScre s.cross and expenses which may in any way..me againn said City /
U Z APPLICANTCor the UNDERSTA gofthis
ND WIL COMPLY WITH ALL N N-POINT Issued by: Dale
SOURCE RE N
7 > Re-roofs
Signature ofApplicardiControIclor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum Wilding occupanutace or handle hazardous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cwc.Section 25532(a)+ All roofs shall be inspected prior to any roofing material being installed.
❑Y
If a roof is installed without first obtaining an inspection,I agree to remove
WIIIcup
s applicant or future building ocantces
equipment a -
. emit hazardous air contaminants as Defined by the BayyAArea Air Quality Management all new materials for inspection.
District?
C3 yes �}ta
I have real the hvand mis materials requirements under Chapter 6.95 of the 0difor.
ria HmIO&SafctyCodc.Satiov 255115.25533 am125534.1 undersand thatifthc Wilding T ^ \ 9 /� 0�
does Out Carmody mans Nat it u my mspovibility,to notify IW occupont of the V
requi¢mcns wk' tw met prior lag arem ort ecnifimte of occupancy. Signature of Applicant Date
Ovwar M.mh Mz..d.g I Data All roof coverings to be Class "B" or better
Sep 1? 04 12: 09p Cosmos Roofing (6501969-9905 p. 2
Cooimuaity Unslopoa-at
10300 Twin Aymn
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-333)
CUPERJTINO
Building De artment
)OB ADDRESS: PERMI'S a 7
'ZO 7 RO��I/NCaG,rZ RgJ 040 90 zz / `
OWNER'SNAME: '3ojZis6uznSEP, PHONE Ijpg e1 +$b47—j
GENERAL CONTRACTOR: FAX#
I am not using any subcontractors;e,t
Signa Date
Please check applicable subcontractors and complete the LgLO—w2ZIttfortnation
SUBCONTRACTOR BUSWESS NAME, BUSINESS LICENSE O
I Cabinets&Millwork
Cmnent Finishing -
Electrical
Excavation _-- --
FP,ndteg —
Hoorinw.Carpeting
— —
Unoleum/Wood
— Glass/ Glazing
Heating --- -
Insulation
i L.Mu scapmg
--
Masonry
Otnaalental Sheet Metal
Painting/ Wallpaper
Paving
- I'luatbin$ --- — ---
Roofing
Septic Tank
Sheet Metal - -- -
Sheet Rock --
Tile
Ile,
Ow Contractor Signature Date
Community Development Department
Building Division
1 � City of Cupertino
4 ,.
�� 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E TIN® 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 with the above stated policy on re-roofing.
Homeowner's Name: /Hp�
job Site Address: 2-0 ?-c79_'Q �) IL(J
Roofing Company Name:
A plicant's Signature: Date: 9 !S O y
Greg teal
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
an REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Addres�
Owner's Na Phone
�! Phone#: iq&_F4
4c 7
Contractor Phone#: License#:
LSd 969 - 7663 2r5gq- /
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt ShinglesAsphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
o Other(Specify) ❑ Other(Specify)
Number of existing coverings 1 ❑ Provide I.C.B.O. Report#
X To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Des iption- pp /� � �nn
/ 0 a /La-Z , Wa-JCct�oS/S• CJ O 30 �pu�a C�
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Pro'ect: oo Type of Constrd t'6h: _ / Occupancy group:
Qty.-if-,,
A �licable Fee ID Fee Description Fee Group
/ BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
1 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
�� � � 7