04060178 1 CITY OF CUPERTINO N
BUILDING DIVISION PERMIT CON'T .A.CTCI2TNT+.UT2MATI01+1
BUILDING ADDRESS: FOUR SEASONS ROOFING PERMIT 11b 4060178
10175 POTTERS HATCT-T
OWNER'S NAME: PERMIT ISSUE DATE
DE ANZA OAKS HOA 645 HORNING ST nr,/21 /2no4
ONE: SANITARY NO. CONTROL NO.
(408) 278-0330
ARCHIMCIPENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300 LICENSEDMetIamCONTRACTOR'S DECLARATION
F 1 hereby affirm Nn 1 am limned under provisions of Chapter 9(commencing Job DOSCTIpnOn
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with gecGon]0(N)of Division 3o NC Business rand Professions Code,and my license is
in full fomeantic e —3� e�72�8 REROOF W/COMP. SHINGLES I/
n z Licenu Clan / Lk M
Date O Co
,e AR HITECI'S DECLARATION
Di tri 1 undcrsun my plans shall M used as public records
Die,
Licensed Professional
OWNER-BUILDER DECLARATION
ef 1 herehy affirm that I me exempt from the Camracmr's License Law for the
following mason.(Section 703 1.5,Business and Professions Code:Any city or county
$ which mquimt a Permit to convect.alter,improve,demolish,or repair any structure
Fiy prioran its Issuance,also Imports the applicant for such postal to file a signed statement
F
that he is licensed pursuant to Me prevision of Me Contractors Learn,Law(Chapter 9 Sq.Ft. Floor Area Valuation
¢�$ (commencing wish Section 7")of Division Sof the Businais and Professions Code)or
tlst he is exempt Memfmm and Ne basin far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permh subjects the applicant to a civil penalty of 3 0 O
not mom Nan five hundred dellGGaaraCa.(MOT). Occupancy Type
❑I,as owner of the propcny,m my employees with wages a their sole compensation,
will do the work end Ne sweture is not intended or offered Tor sale(See.7W.Business
and Profeaziona Code:The Cutaneous Lt.Law dace not apply In an owner of Required Inspections
property who bu Ilds or improves thereon,and wha does such work himseIf or through his
own employees,provided that such Improvements are not handled oroRerel finale.If,
interviews,Ne building or improvement is mid within one year of completion,Ne owner.
builder will have Ne burden of proving Nat he did ran Wild or improve for purpose of
.to).
❑1,an owner of Ne property,am exclusively contracting with licensed contacted;in
contract the project(Sec.71)C4,Business and Profusions Cade:)The Confiscates Li.
come Law does not apply to an owner of property who Wilda or improves therann,and
who contracts for such projects wish a conductorial Handled pursuant to dm Contracmis
License Law.
❑I me exempt under Su. ,B&P C for this Moon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: _
❑I have and will maintain a Canifimse of Conant looelf-insum for Workers Compere
moon,u provided for by Section 37W of the Labor Code.for Ne performance of the
work for which this permit is Wood.
❑1 have and will maintain Workeh Compensation Insurance,as required by Section
37W of Ne Labor Code.for Ne performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Center; /�S �f� Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thhmnion acedra thecompleted if I,Permit is forms,hundred dollars(SIM)
or leas.)
1 certify N*P"'
N r for which Nis permitaissued.l shallnotemployanccomc subjedrot,WarkersCmpusatinLaw'ofCApplicant
NOTICE •r eking shin oaahricatcfExcmplain,you should,come sucaation provisionsofNeLe,rCodeynu must.JO roMwW ots or this permit shill he deemed mvided.
,Z,t F i CONSTRUCTION LENDING AGENCY
ti
[••� I far which
Netmere iWood(So..3 len ding agenry for tiro performance of
tYi ti the work for which Nu permit is issuctl(Sec.J09'f,Civ.C.1
Q lender's Nam.
�z Lender's Address
U 0 1 certify that I have mad this application and sum Nat she above information is
LL F cancer.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and thereby obtain representatives of this city to enter upon the
W
above-menudgm property fond epection purpWhich as.
gy (We)agree m ave,indemnify and keep handles the City of Cupertino against
ssN
liabilities,judgments,of to grats mindof this permit. may in any wayaccrue against mid City
fJ z A APPLICANT
of UNDERSTANDS
Nis permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC�ULATIONS,
Re-roofs
Si rc of ApplicaDem
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Willy f applicant or future iptidingk,Chapter
store2, ondlc hmalth anmamrial
az de.Sed o Ne Cupertino Municipal Cade,Chopmr 9.13,and Ne Health and Safety
otic. Sit,35532(a)? �° All roofs shall be inspected prior to any roofing material being installed.
OF ❑Yea \
Will the applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit haverdnus air contaminants a defined by Ne Bay Area Air Quality Management all new materials S Otion.
District?
❑Yea
Ihavemadshehoomdr smate'elsmquimmens under Chopmr G95ofshe Calif
-i.H.alN&SafctyCodc,Sccdoa35N)5,35533 and 35534.1 ended Kalif Nc Wilding ez/
dos not cunentiy have a tenant Net it is my responsibility m notify tiro occupant of Ne
re vire poor to isaanceofa Qualleamof Oceu ey. Signature of Applicant Dat
e ° All roof coverings to be Class"B"or better
Owner tar authmimd agent ate
Community Development
'. +
@ - 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building Department
JOB ADDRESS- PERMIT #
? a'ttL"^S rix (3
ME ? cel
OWNER'S NA : PHO #
GENERAL CONTRACTOR-
7, FAX #
I am not using any subcontractors: �i c
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
0 e Contractor Signature eDate
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
OUPEkTINO 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 fust 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: Z_ 4,fAv
Job Site Address: rU 7G Pa&t
Roo fing Company Name:
A plicanYs Signature: / � --'��pte: v�� r/
C�til10LX1
Greg teal
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# r'_ Date: 2
J �
Building Add ss:
D 12 s Pa b4 -u s ->�l
Owner's Name:
Contractor: Phone#: Lic6nse#:
Z&t -22 l 6F
Contact: '' ` Phone#: Cupertino Business License#:
-c )lLA S 5-C76 — 0 / Z ( Z
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles �5t Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shinglesgy�pp,�.. ElWood Shingles
Other(Specify) l 60"G✓o ❑ Other(Specify)
Number of existing coverings / ❑ Provide I.C.B.O.Report#
'N<'—To be Removed El Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Polic ❑
Job Description:
Oil >ric� s 4 — h �oTin,s Sa cot., 5
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plann' Dept. if
there are anyrestric ons: LJ
Cost of Project: Type o C s io Occupancy group
Q : i
1• ble 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
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