03060100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT „CONT"' GTOR€INFORMA.TIO.N
..s , u'
BUILDING ADDRESS: CONLEY ROOFING PERMIT NO.03060100
OWNER'S NAME: 5961 INDIAN AVE . 'IT76�/ .L3/2003
NE: SANITARY NO. CONTROL NO.
(408) 448-2656
ARCHTEC(ENGINEER: BUILDING PERMIT INFO
BLDOO ELECT O PLUMB MECH
O 0
r,J0, LICENSED CONTRACTORS DECLARATION Job D cr
u 1 hereby affirm Thal I am licensed under pmvisimu of Lltspter 9(Commencing
Tj with Section 1")of Division 3 of Ne Business soul Professions Code.and my license is
+�< mPonfomeandeif e S1 6 O Z REROOF
en
JUN 2 d ZOOS Z a IJc.p ��
Data Canuactor )
CHTEcrS DECLARATM
I underma.d my Plans mill be used a puhllc recoNs
BUILDING
a Licensed Professional
Cyy OWNER-BUILDER OEMs com ION
a Z I hereby.(Sero that 1 1. exempt from We Cminmm's License Law for the l
p o following wan.(Section 7M L5,Business and Improve.
moroas Code:My oily or county -
5$� which required•permit to ennslNCl.alter,impmw,dunolkh,lir repair any avuctum
�xSn prior to its issuance,also requires the applicant forsuch permiuo rile asigned stsmment
Fp that he is licensed pursuant to the provisionsarrieContruwr'sLicenselaw(Chapter9 Sq.Ft.Floor Area $�/Bl��ion
$ (commencing wish Section 7")of Division 3 of the Business and Professioms Code)or
.. that he k exempt Nemfram and she basis for Me alleged exemption.My violation of
Sectime
7not 0MlevnMyartaiaesoniaufora3Wrmluubjectsdmapplicant tdacivil penalty of 38@IIVOM bHr 00 Occupancy Type
❑Las owner,tiro property,m Is employees with wages u Nei(sole rompenssdr,n,
will pr lesion.envieand o Commumm's Litme Law i�font apply TO",Bulinus Regg[tired inspections
and eny wh once Curie:The Cont our on. lid who law doss not apply tf m ownemush is 307 - I NS ULAT I ON p
pmpeny who buildsorimpmwa thereon.end who dmf each wort himmelfor Wough his
own employee,provided shat each improvements sue not intended oroRered for ask.If. 601 — ROOF TEAR OFF
however.the building or improvement is sold within oro yearof Completion,the owner
builder will have the burden of proving Mal he did not bald or improve for purpose of 602 - ROOF PLYWOOD NAIL
"le')' 603 - ROOF BATTENS
1]I.as Owns,of the property,am exclusively contracting with licensed commcuus m
construct Ne pmjcm(Sec.7W.Business and Professions Code:)The Camicus'a U. 604 — ROOF IN-PROGRESS
cense law docs not apply m an owner of property who builds or Improves Ihemon,and,
who contracts for such pm)eeu with aconuutor(U licensed pursuant to the Contexture.
License Law.
❑I am exempt under See. .B&P C for this mason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hemby anion under porosity of perjury oro of the following declamations:
I haw end will main Wn a CertificateofConsenl to self-imam far WorkefsCompen-
radon,as pmvided fm by Sexaan 3700 of the labor Cade.for the perrormame of the
work for which this permit is issued.
❑I have and will maintain Workces Compen"tion Insuruce,u requimd by Section
"Wolthe LahorC c,for the performance of Mae work er
for which this pmil is luted.
My Wo(kcll Gl aca,far and Policy number yey„(3 Y)) D
Cartier.
Policy
No.: Cl [JU �'/ eJ
CEFMFICA P EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk sectim need act c completed ifthe permit is foram hundred dollan(SIIXI)
Less.)
1 certify that in the pmformance of dm work for which this permit is issued,I shall not
employ any person in any menet,an u in heaeme subject to Me Workers'Compcmation
Laws of C.1 lu mi..Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you Mould
become subject m the Worker's Compensation provisions of the labor Code,you most
.,O foMwith comply with such pmvidom Or this pmmil Mall W deemed revoked.
Z tiCONSTRUCTION LENDING AGENCY
I hereby alfum Net Mem I.a Conswction lending agency for the performance of
3i the work for which this permit is issued(Sec.3097,Civ.C.)
YQ Lender's Name
3 Z Lcndaes Add^••
J 1=try that 1 have read this applieaaon and maze that Me above information k
3. !' coma I agree to comply with all city and County on inancas and lute lawn telling m ,
building conswction,and hereby euthodve mpresentstiwa of this city to enter upon the
Na above-mentioned property for Wpccomr pu(putes.
(WO)agree on an,indemnify and keep harmless the City of Cupenim against
r y liabilities,judgmcnu.coats and expenses which may In any Way amus against said City
J Z in cnmtagmnce of Me grossing of this permit
^ APPLICA UNDERSTAND ND ILL COMPLY WITH ALL NON-POINT Issued by: Date
;ituict?
UR E L ONS.
Re-roofs
mlum of ppb anaacmr Data ` _
HAZARDOUS MA DISROSURE Type of Roof "` f 0 3
Will Me applicant ar forum Wlldin mupantsmrt or Mndlchuardousmau id
defined by the Cofounder,Municipal Coac,Chapter 9.12,and the Health and Safety
ae,section 2ss32(a7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future building Occupant Me equipment or tkvices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamninus airContaminantsas derined by the Bay Amo Air Quadily Management all new materials for inspe tion.
❑Yes ON.
Thaw mad vard
the mamcrialsmquiremcnuundcrClari
up95 ofthe Calif.,.
libHmlth&SatelyCodc.Sccdam25505,25533and25534.1unwc ddutirtM building
eau not currently hew a unam.Net its my respomihility,In notify the occupant of the -
Mquireme 'h bane ' rtoissuanmofaccmrlcawOfOccupsnxx 'gnatureofApplicant - Date
wnm ar.mhenvc t Dam All roof o rings to be Class "B"or better
Community Development Department
Building Division
9 � 1r City of Cupertino
"w 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
�UPERTINO 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: 1r
Job Site Address:
Roofing Company Name: C v� 22
A phcanYs Signature: Date:
\�l/o61IgDt�
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
0REROOF c3 ° 6
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
� � IDZa 3- 0
Building Address: f
Owner's N,prlte�� Phone#: 173
Contractor: Phone#: License#:
� S�3oo2-
Contact: Phone#: Cupertino Business License#:
V4\- SCTo - (0 3 "�
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles -19� Asphalt Shingles
tLT 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.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: �z P
Residential 1PICommercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: oo Type of Construction: Occupancy group:
Qty. if
Applicable 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