05080020 CITY OF CUPERTINO �° r'ms�`.
BUILDING DIVISION PERMIT PRONTRACTOR IlYFQRMATIQN
BU I
22910 CRICKET HILL RDLDINC,ADDRESS: FOUR SEASONS ROOFING PERMIT N°.05080020
OWNER'S NAME: PERMIT ISBUE DATE
LEWIS HELEN L AND ELBERT M TRU5O2 HORNING ST 08/03/2005
NE:
SANITARY NO. CONTROL NO.
(408) 278-0330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
v0' LICENSED CONTRACTOR'S DECLARATION Job Description
Fu F I hereby affirm Net 1 am licensed under provisions of Chapter 9(mmmcwing (,'gam
iq`. . f scction)O(MB of Oivisionlof Jm Business orb Professional and myliccnx is �p T� t� [I �
LiccvmaClued effect C'3 Lie.« .) o REROOF W/30 YRS . FELT & '18111 V\��Illj' FLltn
c t-o Dam Coal, c. 4 0 YRS . GRAND G.A. F.
oi ARCHrTECTS DECLARATION
C i 1 understand my plans shall he used as public rommis
y sea Licensed Professional
OWNER-BUILDER DECLARATION
1 thereby maso .!Sinn that 1 1. exempt from the Contractors Cod License Anyc Law for the is I1 NNW{� �l
00 following mason.(Sm6uo Ronst Business end Profeaivas Calc:Any or county 'nt p+l (t \/ ` 1n'\AI
i m which inquires•permit m ennswet,almq impmvc,dcmalLah,m repair any swesum 11 ,//
prior to its issuance,also requires the applicant for such permit to rile a signed eammeni
'?< that he is licensed puuantxNeprovisionsofdmContractor's Law Sq.FC Floor Area Ae �' Valuati 1 000
rs
9 (commencing with Section]000)of Division 3 of the Business and Professions Cody or
i
that he Is exempt Ncrefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any appli.tfor.permit subjects the applicant m a civil penalty of AppNN niber Occupancy Type
nes mom man five hundred delta.f5500). 3M 2 3 5 012 . 0 0
I,as owner of life property,a my employeas with wages as their sole compensation.
will do me work.and the swcmm is not monied or offered for sale(See.7(1 Business Required Inspections
and Prefessims Code:The Contractor's Liatee e law does not apply of in owner of q p
property who builds or improve thereon,and who does such work himself or through his
awn employees,provided that such improvements art nm momicd ma@rad for sale.if.
however,me building or improvement is sold within arse year of completion,Ne owner-
builder will have the Widen of proving that he did out Wild or improve for purpose of
W.J.
❑h as owner of tau property.am exclusively contracting with licensed conuacmrs to
caasWet the project(Sec.]Ora.Business and Pmfe is..Code:)TW Contracxr's Li-
cesme law does not apply in an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Cumnctors
License Law.
❑1 am exempt under Sec. ,B&P C for this moron
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aff m under penalty of perjury one of the following declarations:
7;k
I have and will mamemn a Certificate of Cement to selhinsure for Worker's Camperion,as provided for by Section 37 M1 or the Labor Code.far Ne performance of me
rk for which this permit is issued.veand will maintain Worker's Compearadon Insurance,as required by Sectionf me labor Code,for the perfann epee of the work for which this permit is issued.
y Worker's Cnm peransation Insurance carrier and Policy numbber aam::rtier. tR t.�.A Policy No.:1L��
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Allis seetipn mead not W campicmd iliac permit is furore hundred dollars(SIM)
or less.
I certify that in me Performance of the work for which this permit as issued.I shall not
employ a my Person many manner x as to become subjectm the Wcmlmm Compenmtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Cadc,you must
.,O forthwith comply with such provisions or this Permit shall he accrued revoked,
Z'" CONSTRUCTION LENDING AGENCY
PI hereby affirm that there is a construction lending agency for the performance or
r! 7 the work for which this permit is issued(Sec.3M.Ci,C.)
Igl Lenders Namc
4. I<nder's Address
�z
U O 1 certify that I have rtad Nis application and sate that the mauve information It
U. F-' torten.1 agree in comply with all city and county oNinarms and sate law relating m
O U Wilding construction.and hereby aumorim representatives of this city in cater upon the
above-mentioned property,for inspection purposes
(~ gy (We).,me to save,indemnify and keep harmless the City of Cupertino against
ret limbilitia,rydgmcas.cau and expenses which may in any way sec=against mid City
U z APPs Paramit.
LICANTeUNDERSTANDS Aof 6c granting of nND WILL COMPLY WITH ALL NON-POINT Issued by: Date �-'� -lJx
SOURCE REGUi C,
Re-roofs
Sig.... mApplicaruComactim Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futum Wilding oeeupmt more or handle harardous maarim
as dclincd by the Cupertino Municipal Coda.Chapter 9.12,and the Hcahlt and Safety
code.scenes 25532(a)?
Ye All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingacupant usecyuipmem ordcvias which If a roof is installed without first obtaining an inspection,I agree to remove
it hammous air conuminants as defined by the Bay Area Air Quality Management all new materials for inspection.
unci?
❑
yes
I have rtad dm amadous materials requirements under Chapter 6.95 of the Calila,
nu Hmlth&SafctyCmi Sections 255115,n533 met 25534.1 undaunted and lithe Wilding g—3—Q,
docs not eaamly hart a tensor that it is my responsibility to nod fy thc acupmt of the
mgmmmerai:k x etpdawimuaraoraceNr, tearoccup.nay. Signature of Applicant Date
Owner orauthomedaPmt Date All ro rings to be Class"B"or better
r- - Community Development
10300 Torre Avenue
.' ' 4✓ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: PERMTT #
a
OWNER'S NAME: PHONE #
GENERAL CONTRACTORS J s FAX #
I am not using any subcontractors:rG-t7�,
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
r Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
*CIOF Fax: (408) 777-3333
UPEI�TINO
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 withbut first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can by performed.-
7. NOTE: If you call for a plywood `nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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 thee/above stated policy on re-roofing.
Homeowner's Name: le /;S, damn-C
Job Site Address:
Roofing Company Name: JrJ 6A 49 J �
� � L16C
Applicant's Signature: Date:8,2-05
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
aCITYOF REROOF
ICUPEKTINO PERMIT APPLICATION FORM
APN # Date:
U
Building Address:
/
Na
Owner's me: Phone #1
AM�
Contractor: 1 OnI
Phone °8 License #:
J r
Phone #C'10,9) Cupertino Business License #:
Co tac
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)0141,4 ❑ Other(Specify)
umber of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
b Descripti /
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Co of Project: e of struction: Occupancy group:
Al
Qty. if
Applicable Fee lD 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
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