04060129 CYPY O CCUPERTINO "'` *
BUILDING DIVISION PERMIT f CONTIUlb, R IIYT(CSI.tMe�'L'Id)Ns
BUILDING ADDRESS: LOS GATOS ROOFING PERMITNO0 4 0 6 0 12 9
853 LONNA LA
aWNER'S NAME: PERMIT ISSUE DATE
Aft SUSAN DAVIS 1771 SMITH AVE . 06/15/2004
ONE: SANITARY N0, CONTROL NO.
(408) 298-9399
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEOCH
Y00 LICENSED CONTRACTORS DECLARATION
�m❑ 1 hereby affirm Nat I am licensed under provisions ofChapor9(commencing Job Description
tei with Section 7").f Division 3ofNC Real.and Pmfe¢siona Code,andmylicenuis
^ � m mR foreaandeffecl - CF-00707 REROOF [�A`f}T '(tea py���
n v`S Z
License Clay / J Conmuch r 'g �� ^�``+ E sem+
Y 931 ARCHITECTSDECLARATION
J
Y e l undcraond my place¢hell W mad u luhlic mcnNs UN 21 2004 200 4
4
j� Licensed Professional '�I/'
OWNER-BUILDER DECLARATION y
aZ I hereby affirm that 1 am exempt from Ne Contractors License Law for the �e,'�pe�ga'�
O O following reason.(Section 7031.3,Business and Professions Code:Any city or County BUILDING
t�
which.quina a permit to conromea,offer,improve,demolish,or¢pair my street.. $6126
F�P�2 Inform its issuance.also requires the applieam forsuch permitto file a signed aWemenl
that he is liccnud pursuant to the provisions of the Contrmmr's License Liw(Chapter 9 Sq.Ft. Floor Area Valuation
21$ (commencing with Section 7")ofDivision 3 of Ne Business and Professions Code)or
Met he a exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.3 by any applicant for a Permit subjects the applicant m a civil penalty of a Occupancy Type
not more Nm five hundred della.(5300). )
D I,m owner of the property,or my employees with wages u their sale compensation,
willdodieworkandde, mucturc is not intended osoffered forsaic(Sec.7044,Business
and Professions Code:The Contractor'Liccnae Law does trot apply be an owner of Required Inspections
property who builds art improves thercon,and who does s rich work himsel f or though his
own employees,provided matuch improvements au not meanded.,.Mored forsole.if,
however.the building or improvement is said within one you of completion,Ne owner.
builder will have the burden of proving mel M did not Wild or improve for purpose of
aalc.),
D 1,as Owner of the property,am exclusivaly corseting with licensed conesctors to
construct the pmjecl(Sec.7W,Business and Professions Code:)The Conueuor's Li.
cense law does not apply to an ownu of property who Wilds or improves became,and
who contracts for such projects with a Condiments)licensed punumt to the Contnetors
License law,
D 1 am exempt under Sec. .B k P C for Nis mason
wart Dots
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
D I have and will maintain aCertlficate of Comenlm self-insure for Warker's Cooper.
Cohen.as provided for by Smile.3700 of the Labor Code,far the performance of the
work for which this peril is issued.
❑1 have and will maintain Workers Compensation Insurance,m required by Section
3700 of Ne Labor Cade.for Ne performance of the work for which this permit is issued.
My Worker's Compensation Insurance Cartier and Policy number am:
X Ca erre S/V/Z Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W cemplefed If the permit is formic hundreddollors(SIM)
or less.)
1 certify that in the performance of the work for which this Permit is humid,l shell not
employ any person in my manner so as to become subject to LW Worker!Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Coniine,of Excmptimn,you should
buome subject to the Worker's Compensation provisions of the Labor Cndc,you must
,JO forthwith comply with such provisions or anis Permit shall be deemed invoked.
'z CONSTRUCTION LENDING AGENCY
(.n 14 1 hemhyafrrm Nat Neu is a Construe(lon lending agency fm Ne performance of
IYi the work for which this permit Is issued(Sec.3097,co,C.)
aQ Lender's Name
z Lender's Address
U 0 1 certify that 1 have read this application and sum that the above information is
[L F correct.1 agree to comply with all city and county CNimres and sole laws relating to
0 U building construction,and hereby autWrien representative of this city to enter upon Me
LT7 shove-mcubmind property for impcction purposes.
gys (We)agree m¢ave,indemnify and keep harmless the City of Cupertino against All
IA Imbilitiu,judgmcnts,costsand.......hich may in anyway moueagaimla id City
U Z in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS ANP WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU S.� r J y l/
6 / ° Re-roofs
Signature of Applicam"nummor0�—
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Me Cupertinoant Or
building e.Chapter
one 9.12.handle h Health
a mamrial
M defined by the Cupertino Municipal Code.Chepfer 9.12.and the Health and Safety
ode,Ceres 255324n
Dyes 0. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air Contaminants as dchned by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes PNo
Iban reoil Node Sections m05,25l. qui and
under
rommun493 ofthc Cxfifor-
ria Nene.Safety Cndc,Secants et it is 3333and23334.1 ser our,tth scup Wilding \JC/ (/� !/� C s/ ,✓ t"
Jots not curtcndy nave a fenenh Net it ti my resportsihility m nodl'y the mculant of Nc �J /
.quiremcno warty �y pri ilium efe CcrtiOCam of Occupancy (Signature of Applicant Date
6 J X/Id'
owmrmr ammorimd age. Date All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPEkTINO.
Building Department
JOB ADDRESS: PERMIT #
Cgs- 3 L.c)n/Na �„� oYo60
OWNER'S NAME: 5 u 3 A14 DAvf S PHONE # 4'o 9 2,98 93 9
GENERAL CONTRACTOR p 5 6ATns�jeo�a��NL FAX # y09 Z,19 - 73-7 /
I am not using any subcontractors: / C /�I7 -,1\ ��S' o
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Con actor Signature Date
Community Development Department
/x' Building Division
City of Cupertino
10300 Tone Avenue
CITY OF Telephone: (408)777-3228
U P E kT I A I O 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 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 c ly with theTsla
e stated policy on re-roofing.
Homeowner's Name: SUSCi.l1 VI S
Job Site Address: ,3
Roofing Company Name: rr4J 0 S d O I
L
A plicant'(s S�ig^nat�ure: � Date: � 6 '
Greg teal
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
CITY OF REROOF v 6 U
CUPERTINO PERMIT APPLICATION FORM
APN# 359 --,_ l 9 -- 0 2 7 Date: �
Building Address/:
853 Lonna Lane
Owner's Name: Ph #:
Siksar) Da V e M3a -8 S'Wo
Contractor: J D S & - 0 s hone o 3 License#: 900
Q
Contact: �o #. � _ Cupertino3usa�es$License#:
Ty of Roof Covering: //�� II
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
)!� Asphalt Shingles )K Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
Wood Shingles ❑ Wood Shingles
❑ Other(Specify) 'jd Other(Specify) OS 1pers
Number of existing covenngs7— ❑ Provide I.C.B.O.Report#
XTo be Removed X Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: c� �0�� rs , 74 S 14 C�
Re roe -- Tea r 0-P-` 2 er�s7 �.�
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Cons ction: Occupancy grou
/2G . - t
Qty. if
Appl4blp Fee ID Fee Description Fee Group
CLI
BPERMFEE Bld Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
2�s767
27 7°