04080193 CITY OF CUPERTINO "',;,a7 °' "
BUILDING DIVISION PERMIT ` CONT"C COR INF RMATIUN"�
BUILDING ADDRESS: FOUR SEASONS ROOFING PERMIT 7'04080193
AM�OWNER'S NAnF,MC:ANZA PERMIT LSSUE DATE
ONE: SANITARY 0. CONTROL N0.
ARCHITECT2NGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
y0o LICENSED CONTRACTOR'S DECLARATION Job De I
u1 hemby effvm that 1 em IianxO under provisions of Chepmr 9(commentlng
�' with
u S do 7agp of Division Sof arc Buvn"send Professions Codc.and mylleen¢is
^ yml mlf andercay REROOF
�Z License lasso�"" -3q LIwX
Oam p-- "Pay-
ARCHITECTS ` e
CTSZZ 2004
I undersand my plans ahall he usod as public Ids
Licensed Professional BUILDING
5 OWNER-BUILDER DECLARATION
Q 1 hommy alarm that 1 am exempt from the Contractors License Lew far the
9: fallowing moon.(Section 7131.5,Business and Professions Code:Any city or county
>e 0 2 which requires a permit m construct,alter,improve,demolish,or repair my structurenoo
to poor to its issuance.also mquima the applicant for such permit to fie a signed statement
that he is licenced pursuant 10 the provisions of the Contractor's Limme Law(Chapter 9 Sq.Ft.Floor Area Valuation
FCa (commencing with Section 70D0)of Division 3 of the Business and Pmf"sions Code)at
i 3 that he is exempt therefrom and Ne basis for Ne alleged exemption.Any violation of
Section 7831.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 41i2`bI31d10i1VCr 0 0 Occupancy Type
not mart than fin hundred dollars($500).
❑1,m owner of the property,or my cmployen with wagesas their role compenssdon,
willdo the work,md domesctumicamin¢nded OroBered Road.(Sec.7W.Business Required Inspections
and Professions Code:The Contractors Lianse Law docs not apply to an owner of q P
pmpeny who builds or ire proves themon,and who doe such work himal f or through his
own employees,provided that such improvements am not intended croffered for tele.If.
however,Ne building or improvement is sold within one year of completion,the owner-
builder will have Use,burden of proving that he did not build or improve for P.M.of
sale.).
❑1.as Owner of the property.em"elusively commeting with licensed conumicas to
construct the pmjcct(Sea 704x,Business and Professions Cotler)The Contractors L-
ceve taw docs not apply to an owner of property who builds or improve daemon,and
who contracts for such projects with a comeactor(a)llansed pursuant to the Contractors
License Lew.
❑1 am uempt under Sec. .B A P C for this mason
OwnerDem
WORKER'S COMPENSATION DECLARATION
I hereby eretm under penalty of perjury one of the following dalarations: - -
I have and will maintain a Certificate of Consent to self-insum for Workcr'sCompen-
70371'W
ion,as provided for by Section 37110 of the labor Cade,fur to perfomence or the
rk for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance,as mqumul by Section
of the Labor Code.far the Performance of the work for which this Permit is issued.
yLWoorkers Compensation insurance ani Rcy number7'C1f�ea6kL4sG .� No.: fsaCb ` t��bI_ sJ0
CERTIFICATE OF FJ( ON FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not M1ecumpletN lithe Permit Is foruaehundrcd dollars(S100)
,docs.)
1 cenify that in the performance of the work for which this Permit is issucd.I shall not ,
employ any person in any manner so as M become subject to the Warkers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 Q forthwith comply with such provisions or this permit shall be dammed revoked.
Z CONSTRUCTION LENDING AGENCY
[^t4 I hereby affirm that then is a construction lending agency l'or me perfurmance of
G'> to work(a,which this Permit is issued(Sec.3097,Civ.C.) -
W Q Lenacr's Name
1<ndees Addmse
U Q I certify that 1 have read this application and state met Ne above information is
Iy (~ correct.I agree to comply with all city and county ordinances and auto laws reading be
0 f, building construction,and herebymemadn representatives of this city to order upon the
W above-mentioned property,for inspection pu0maes.
a (We)agree he save,im mriry and keep harmleas the City of Cupertino against ^
tr N liabilities,judgments,cuts and expense which may In any way accrue against said City
in
U.Z.r
APPLICANT OUNDERSTANDS of the grarating of AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC U TI
91-711-19y Re-roofs
ignmumof Applicam/Co or Data
HAZklBDOUSMATERIALSDISCLOSURE Type ofRoof
Will the appliam tar future building occupam stoneorhendle hazardous material
as deRaed by the Cupenim Mu
ipal Code.Chapter 9.12,and dao Health and Safety
ode,Section 25532(a)7 All roofs shall be inspected nor to an roofing material being Installed.
❑Yea No P P Y g $
Will the applicant or future���,bbbbbbuilding aculat' use equipment or dcvicv which If a roof is installed without first obtaining an inspection,I agree to remove
mil havardo.air mmaminan JcOncd M1y the flay A.
Air Quality Management all new materials forinspection.
Disuict7
❑Yes Nu
1 have mail the beaardaus materials requirement;under Chapter 6.95 or the Califor, y
.is Health S:Safety Cade,Sections 25505.25533 and 25534.1 undersand that it the building
dens ly h sc'moan my rtapovihility notify me party. t of the
rcqui c �a st m5tpnarmiuvnccofaCcni! tear Occupancy. Sig'atureofApplicant Date
23-oy All roof coverings to be Class"B"or better
Owner or authod'rcd age.11.1 Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
Z28S.S' Po \ar GtMo C. . O ,-(() $ Ol't3
OWNER'S NAME: a, %64 �„� , PHONE # o e 2 t&-
GENERAL CONTRACTOR: t FAX #
I am not using any subcontractors:
Signatur 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 y-�210 8
Septic Tank
Sheet Metal
Sheet Rock
Tile
i
J $ 2.3. O y
Owner/Con or Signature Date
aM
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
*UPEkTINO
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 'r 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: t l).o,J !�
Job Site Address: 228'SS. Po 41 a r G ro vG.
Roofing Company Name: ^ Fo pa r SC QS o r.S �eo F�N
A plicant's Date: $ ? 3•o�(
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# 3 `123301 - Date:
Building Address:
Z28's.9- Po 1a.- Grove-
Owner's Name: Phone#:
l/J0NC, 1 EM1� — DeA,ti?.a U'A1Ls �koA Cttov) 2.-1$-0330
Contractor: Phone#: License#:
oh s p C4o8) 2-I8 -033a Lt7210�
Contact: Phone#: Cupertino Business License#:
CAO-L 5 nA7-AV-VS ( 00 S CA 0 -01
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles )d Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
Other(Specify) CEµwtw O ❑ 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: ❑
Job Description:
'1:6-1S-b ce.,..u,. odc' ', S+�t1 V-&2121=1C,(2FkM,;�GSL1.GR SAI-1
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning De t. if
there are any restrictions: LLJJ
Cost of Project: J Type of Construction: Occupancy group:
126s10� .n 1.. �
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