03050144 CITY OF CUPERTINO
BUILDING DIVISION PER RT oiMRACTOR TN' U ATTU
BUILDINO ADDRESS: DAVE SMITH ROOFING P"'OMITNo03050144
Sig gnT,T TNC.T7.R RD
OWNER'S NAME: 1052 KELLY DR 9/2003
GUARA CHARLES
NE (408) 973-9427 SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BO ELECT PLO O
30oLICENSED CONTRACTORS DECLARATION JbDescription
I hereby affian that 1 am licensed under provisions o
of Chapter 9(commencing
MN See' 7 )of Division 3 of the Susi andititcalons Cade.andmylicenses
In full fora effaL, .3�
License CluY SCI �C'�,/.3 � REROOF
C(e.g 't� PLpnn �
���
DoteARCHr1ELT5 DE Or
ATION - Lt� p`J
d� vt371tAiasndmy plans"I be used ss ublic meards JUN
5y ted
Licensed ll�llnal ^ A 2003
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Conhantaes License Law for the ,I
`o 1. ��
o following Mason.(Section 7131.3,Business and Professions Code:MY city or aunty - �Y
$� cx
which requires a permit to nsmuct.she.improve, B
pro
,demolish,or repair any structure
Zi prior In its issuance.also acquires the applicant for such permit to rile a mimed statement
pp <
Max heulicensed Inmuntmthe InousionsofNcComment's Lima.LAW(Chapter 9 Sq.Ft.Floor Area $'/N�lpgion
$ (commencing wish Section 7000)of Division 3 of Ne Business Rod Profeulans Code)or
Nar he s exempt thamfrom W We basis for Ne alleged exemption.My violation of
Section 7031.5 by any applicant for a permit mbjecls the applicant o a civil penalty of0 0 Occupancy Type
ant roam Nan Eve hundmd dollars(55001.
❑1,As owner of W property,ar my employees With wages u Near sole compenution.
wi0 do Ihanrk and NesrMudme s nst NUMed maRW forsak(Sa.70N,BudMw
Rod Professions Cade:The Commences Limn:LAW dens not apply ban awns,of Required Inspections
property who builds or im prow Herman,and who does such wark himself or d amegh his
own employmA,prodded Nat such improvements am notimendW a offered for We,If.
however,Ne building or improvement is Sold within ars year of completion.the owner.
Wilda will have Me burden of pmving Nal he did not(wild OR improve far Purpose of
sale.).
❑L a awns,of Ne property am emlus and cnnuaNng wish liaved enom ies's i.
cemuua d esAct apply
in an owner
of and Aawmlons CodeI The Wmramon,1.4
cense contracts
darn oat app1Y c an owns of mosony who Wilds or imProw Neuron,and,
who .Lacs faransh vesicas NN a eonvantw(U licensed pursuant w tiMConmanaM1
Lhanae exce
❑lam exempt undo See ,B&PC(ar NS lnton '
Owner Dade—
WORKER'S
auWORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury arc of We following dalamllons: -
I have and will maintain a Certificate of Conant N selfdmum for Wmkeea Compere
ssdan,u provided for by Sadao 3700 of Ne Labor Cade.far Ne performance of Ne
wok for which Nu permit is issued.
❑1 have and will maintain Worker's Compensation Inmuarwe.u mquimd by Section
3700 of Ne labor Code,for Ne performance of Me work for which this permit is Issued.
My Workeea Camnyemedon Insurance anis and Po'l'tryfpumhar am: I.
Carni /"tC hv✓t�pplicy�gar ^I
CERTIFICATE OF E%EMMONFROM WORKERT,
COMPENSATION INSURANCE
(Tits radon reed mat ha campletetl i f tiM permit Is(mane hundred da0an(S 100)
or less.)
I anify Nat in Ne perform sew of MM work far which this Permit is issmA.I shall ant
employ any person in any mannsrso As N became Subkcl to Iha Workers'Compensation
Laws of CdifamiL Dau
Applicant
NOTICE TO APPLICANT.If,after making this CeniBau of Exemption,you Should
become subject in the Workers Compenauon pmvieons of the Lobar Code.you mute
,J 0M
fowith mmply with Such provisions or this permit shall be deemed malted.
.Z.t y CONSTRUCTION LENDING AGENCY
[� Ihamby AT.Net Nem is a caawninn lending agency fm Ne performance of
a
We wwh for which this permit Is issued(Sec 3091,Civ.C.)
QLendees Name
r'7 Z Lenders Mdress
U0 I certify Nat 1 have mad this application and sou Nat Ne above InfarmNun is
114 E emmeL 1 agreeam
to comply with all city and county ordinances and u Ian misting to
C)rVbuilding contraction,and hereby authoMm representative of this city to enter upon Me
Til ahove-mentioned property for institution purposes
tyyt�,, (We)agree in nw,Indemnify and keep harmless Ne City of Cupertino against
�rjj Ilabilitia,judgments,costs and expenses Which may In my way name again!ssid City
U Z in consequence of Ne granting of this pmeh.
CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E LATIO
S 32 Re-roofs
Si of ApplicanVConmcmr Dalt ,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sore arbandle hazardous material
As defined by Ne Cupertino Municipal Code.Chapter 9.13,and Oar Health and Safety
ode,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea Na
l If a roof is installed without first obtaining an inspection,I agree to remove
Will-d Ne applicant r forum building aeupam tax eyuipmem a,devices which
It h07AVEMa air comsminums u Uefincd by the Bay Area Air Quality Management all new materials for inspection.
kild"7
❑Ya No
Ihaw mal Ne Mai
msmaurialsmqulmmewunder ChapMr G95ofUM Califar. 2 Z
nit HmiLh&SafciyCode, aom355O5,25533am125534.lunde.dOuif Ne Wilding S— fL�
not currently have a Masai,Nat it s my rapomihlllly m sadly rile occupant of
M nsWhich m met prior R,usuanceofa of upwwy. 1 nature of Applicant Date
S z9-�3
Owner or Authorized Agent Date All roof coverings to be Class"B"or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
a?TY1F Fax: (408)777-3333
IUPEkTINO
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: 11 G✓ `�C r a e ( ) �
Job Site Address:
Roofing Company Name:
A plicanfs Signature: Di e: Z 03
\�1/�61h10t�
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO 3 OS-0 / 4 L�
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# 2 � 0 Date: \
cJ � � �/ V
Building Addre s: �� I 4e<
Owner's Name: Phone#:
qe�sep-
Contractor: Phone#: Q13-9 , j,� License#:
Da s , , � " L
Contact: --Da V_A1 Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles — Asphalt Shingles
Wood Shakes ❑ Wood Shakes
Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
aI Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description e 44 ---r k 5i l) 1/2 0 S t3 n S '9�
q� eoro� �o �0 II�
Residential Commercial ❑
Fire Zone: Yes Confirmed with Planning Dept. if
there are anrestrictions: LJ
Cost of Pr ect: s Type of Construction: Occupancy group:
� epv
Qty
Aca ell 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
# 7 �
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