04090272 CITY OF CUPERTINO �' �; «# ' w
BUILDING DIVISION PERNIIT COt\tLRAC'�TOO R INF®RMATION -
*�, ,;:; „ . -
BUILDINGADDRESS: R E ROOFING & CONSTRUCTION 'M"04090272
OWNER'S NAME: PERMITISSUEDATE
Alk LEE LIMBURG
ONE: SANITARY NO. CONTROL NO.
(408) 925-9995
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
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LICENSED Our I a hoorms CONTRACTORS DECLARATION
Of CON Job Descriptio NAL E D
wC I hereby affirm that I nm ONTRA undo provisions of Chapter 9(commencing u v
iW with Section 7IXYJ)af Mi nthc Buminess o ions dmyliccnm ix
n ' in fullforccandcffa °pj ''`� '�S REROOF W/ ASPHALT SHINGLES
q= Lieenma Lie.a
o Da Contra mr OCT G 2004
ARCHITECTS D
g n I undcrsanJ y plans shall be umJ public rc
>neU C�
3 G l Licensed Profbyxiond p O II It t) D fl
O e D LA RATION U 'ILIIS I�IV\\\\)11)1
1 teres affirm that m exempt C s License Law for the
O o following mason.(Section 7031.5.Business and Profs bns Cade:Any city or county
K m ff. which requires a permit to construct.aftm,improve,demnlbR or repair any mu reLmn
v—'^ prior to its issuance.also inquires the applicant forsuch permiuo file a signed statement
that he is lixenmdpunuantmNepmvisioosoflMConuactur'sUnnic. aw(Chap¢r9 Sq.Ft. Floor Area Valuation
¢L_$ (commencing with Satio0700(1of Doision3of the Businemand Professions Cade)ur
dm he is eaempt Ocmfmm 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 or 31h&N31I1"cr00 Occupancy Type
not mom Orion firs hundred dollars(5500).
Ol,ssownm of He pmpcny,or my employees with wags es their sole compensetlon,
will do Newark and the swcture is not intended m offered ror.salc(Sec.7044,Business
and Professions Coda:The Cortractor's Lienee law does nut apply to an owner of Required Inspections
pmpcnywho buildsmrinta o ns Hereon,and wh.dresaueh work himselrorthroogh his
Own employ=.provided Hat such improvements an,not intended oro0aed formals If.
however,He building or improvement is sold within one year of eempledion.He owner-
builder will have the burden of proving chat M did not build or improve for purpose of
ale.).
1,as owner of He property,am exclusively contracting with licensed convectors to
constmet the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
come Law dors not apply to an owner of property who builds or improves Hereon,and
who contacts for such projects with a eontnctor(s)limnxd pursuant to the Contractor's
License law.
O I am exempt under Seo. .B At P C for Oct mason
Owue Dam
r WORKER'S COMPENSATION DECLARATION
1 hereby of ion under penalty of perjury one of He following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compere
motion,as provided for by Section 3700 of the labor Code,for He performance of the
work for which this permit is issued.
1 have and will meimain Weaker's Compensation Wor ance,as required by Section
3 W o'dm Labor Code,for He performance of He work for which mu permit is issued.
Workcfs mat,vmatdo li�wnn¢caries and Poliq nu Mr arc:
Cartier. r1I kS YtA Policy No.: 'l(l
CERTIFICATEO %EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This onion need not hccompleted irthe Permit is fmfonc hundred do]].(Slot)
or less.)
I unify that in the performance of the work for which this Permit is issued,l shall not
employ any Person in any manner an as an become subject to Inc Workers'Compcnation
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If.after making His Ceniremn of Exemption,you should
become subject to the Worker's Compensation provisions of the tabor Code,you mum
Z forthwith comply with such provisions or His Permit shall he deemed rooked.
'PO CONSTRUCTION LENDING AGENCY
PIhereby affirm that chcre is a constmninn lending agency for the performance of
:4r1 He work for which this Permit is issued(Sec.31197,Civ.C.) /
US Q Lender's Nation
2'
Z L< Add.ces Add
U
[.7 0 I certify Hat I have mad city
application county
sum Net He above infomutiun to
(y H builds,I ogre m comply with all city and county oNinaa of and some laws r upon
c
C.1
above
-mentioned
hereby mutation purposes.rivu of His citymcnmr upon He
W .nave-(We)a re propene for inspection o l kup
G
(We)agree m ave,indemnify and keep harmless the City of against against
Er N liabilities.judgmcnu.cosu and capcnsca which may in any way attruc against aid City
V mcon ue.ccafthe granting of is permit.
/^ APPCI UNDER S A WILL COMPLY WITH
�ALL N N-POINT Issued by: Date
l'
\/\ CE xi S_ / II Z�O
Re-roofs
Sig ocuN
ns ca ppliConuad Date
HAZARDOUS MATERIALS DIS 'sYi� Type of Roof
Will Heappfl�t or future building excupam nom or handldi'mmrduus mammal
as defined by the Cupertino Murder Cock.Chapter 9.13,and the Health and Safety
Code,Section 25532(x)7
All roofs shall be inspected prior[o any roofing material being installed.
❑Yes
No
Will the applicant or
four
building oeeupam use cyuipme evmes wmmh If a roof is installed without first obtaining an inspection,I agree to remove
mit ha.rdoux air contaminants u dosed by the Bay Area afdy Mmogcmmn n aterials for ins ection.
Di nice]
❑Yes
IhavcreaJHehe,Socw mamdalsreyuimmenuunder ap¢r omit He Cal nry n q
nie HcalH&Safoy Cnk.Sadons75505.35533 ad]5514.1 unJe dthmifNe kuilJc
my rcaponsihilitymnntil y the upas til no
mq ' ldcbm t tpd tocan of a mrumlenroe "ye —Slgna-fureofApplicant Dale
t notcedagentDam All roof coverings to be Class"B” or better
.� Community Development
10300 Torre Avenue
to
Cupertino CA 95014
a Telephone(408) 777-3228
CITY 0, Fax(408) 777-3333
�UINO
Building Department
JOB ADDRESS: I U 3 2� ��IL�R� ���� �� PERMIT 11 04_ 09 0 2 2 2
OWNER'S NAME: L % PHONE # U k- 2 - 2 3
GENERAL CONTRACTOR: yba jrtK 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 t�
Roofing — t /c}t f�l1J Ill 1 h�C
Septic Tank
Sheet Metal
Sheet Rock
' e
0
Owner/ c or Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
IIS Fax: (408)777-3333
OUPEkTINO
Building Department
artment
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 Ithe above stated policy on re-roofing.
Homeowner's Name: ��1 l�lM BURS(
Job Site Address: I U 7J2(o 0AA, Km fi1Ztzu Lfh 1�
Roofing mpany Na (h( C
1
A plicanYsSign e: ate:
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
SCITY OF CUPERTINO
REROOF2�Z
CUPERTINO PERMIT APPLICATION FORM
APN# i �_ Y4 Date: II ZgIU�
Building Address:
Owner's Name: �`M UR Phone#: U I - zt h _
Contractor: Phone #: License #: i 0 7 7 7
Contact: Phone#: c Cupertino Business License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
>1Asphalt Shingles �: Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings �Z_ ❑ Provide I.C.B.O.Report#
To be Removed — 2- ❑ Provide Mfgr, Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: 2 LlC4tlt-8 U'F Cort?, Ir45Tk1-c. I.,-U q-STM
Residential ❑ Commercial
Fire Zone: Yes ❑ No rV Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: W Type of Construction: Occupancy group:
Qtyyif
Apglicable Fee ID Fee Description Fee Group
O 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