04090222 CITY OF CUPERTINO
' BUILDING DIVISION PERMITIN' 'NU12MA�ION -
.. �"..:
BUILDINGADDRESS: APACHE ROOFING PEaMITNCO 4090222
OWNER'S NAME: PERMIT ISSUE DAM
SERG
ONE:
SANITARY C OL NO.
ARCHITEC rENGINEER: BUILDING PERMMNFO
EL P MECH
0
LOp LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Out 1 am licensed under prevision[of Chapter 9(commencing
with Section 701bi of Division Sof the Basins and Profamot.Code.andmy license is
D-7
- mmnmmeanAc /I513 REROOF W/ DURALITE SLATETILE
s�: LicenaeGl 3 q OCT3 2004
0 Dam O Co.lndar
ARCHDECTS DECLARA ION BUILDING
1 undcmmnd my plans shill be used as public mcnms
iCr^ Licensed Profcuinnal
HOWNER-BUIIDER DECLARATION
1 hereby affirm that 1 am exempt form the Circe mcmr's License Law for the
a D following reason.(Section 703 1.5,Business and Professions Code:Any cityor county
+�$ which requires a ro mit to construct,alter,improve,demolish,or repair any structure
F prior to its issuance,also requires the applicant for such permit to file a signed statement
Z< that he is licensed pursuant to the provisions of the Cmd.mr's License Law(Chapter 9 Sq.Ft.Floor Area Valu ion
zt (commencing with Section700(y.f Division 3 of the Buxinessand Prafdsxjmx Code)or
3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of nAvairi g.�al
Section 7W 1.5 by any applicant for a permit subjects the applicant m a civil penalty of 3 x'a inV LLWmeT00 Occupancy Type
not more than Eve hundred dollars($501p.
❑1,m owner of to property,or my employees with wages as their sets compensation,
will do the work,and the swcium isnot intended or offered for sole(Sec.7014,Business
and Professions Code:The Connector's License Law does not apply in an owner of Required Inspections
property who but I ds or im proves thereon,and who does such work Nmsel f ar through his
awn employees,provided that such improvemenuam not intended oroRered formic.If,
however,the building or improvement Is sold within one year of completion,the owner.
builder will have the human of proving that he did not build or Improve for purpose of
ale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
comtmct the pmjeci(Sec.7014,Business and Profusions Cade:)The Convutor's Li-
cave law does not apply to an owner of property who builds or impreves thereon,and,
who concocts for such projects wit a contractor(s)licensed pursuant to dm Contractors
License Law.
❑lamexemptunder Sec. ,B&PCfarthismmon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1tiohave and will maintain eCertlficateaf Co...,m xlGinsure for Worker's Compton.
m 37MpravidrA for by Section 3] of the Labor Code.far the performance of the
work for which Permit pcis is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
00
0of the labor Code,for the performance of the work mrwhich this permil is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier, S- q ti Paltry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not uncompleted if the poo rthis for onehundred dollars(SIM)
or less.)
1 certify that in to performance of the work for which this permit is issued.l shell not
employ any person in any manner so as to become subject o the WorkeK Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become a.bj.t to the Workers Campcnsatmo provisions of Ne Labor Code,you most
.JO forthwith comply with such provisions or this permit shall w decmcd revoked.
y CONSTRUCTION LENDING AGENCY
(tip l hereby afore and Nem iso construction lending agency to, ponormanecof
�i 7 the work for which this permit is issued(Sec.3097,Civ.C.)
GQ Lender's Name
r7 z Lender's Address
U Q I certify that I have mad this application and sate that the above information is
ft,r correct.I agree to comply with all city and county ordinances and sate laws relating to
C) building concoction,and hereby authariM remostmodsm of this city to color upon the
W above-amot uned properly for inspection purposes.
gy (We)agme'm save,indemnify and keep humlem the City of Cupertino against
h liabilities,judgments,costs and expenses which may in anyway accrue against said City
V 7 in consequence of to granting of this Permit.
P APPLICANT UNDERSTAb1W AND WILL COMPLY WITH AI.L NON-POINT Issued by: Date
SOURCE REGULATIO f
::r2 `(f Zl o`( Re-roofs
Signatumol'Applicand/Countrogfor Dloro
HAZAR OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hamrdous matelot
m OcBnetl by the Cupenino Municipal Cade,Chapter 9.12.and the Health and Safety
otic,Section 25532([)?
pyre QXa--- All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7dom
mil hmamnm air armamtrums m defined by the Bay Ama Air Quality Management all new materials for inspection.
❑Ycs
Ihave&Safet thcde,Secmrs 25505.25533remunts 5534.IrChapadmatif the Caldingn Wr&SafetyCom,Seedom Oat it is yrsnd75534.1 indemtandamiftheb,of the not currently Aavc a tenant.Nat it is io rcaponsiccot ic notify Nr,occupant of theyuirem met prior 'muanceafaCenifmateo�0e pan Signature ofAppl' ant Date
Owner All roof coverings to be Class"Bor authoriv gent Dam
"or better
Community Development
�pJ10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
•CUPERTINO
Building Department
JOB ADDRESS: PERMIT#O Y O 9 O ZZ Z
�11 -.;i,<I, r6 .
OWNER'S NAME: PHONE # Z o
GENERAL CONTRALTO FAX#
I am not using any subcontractors: (tea c� {T . ,' LZ
Sign ture� 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
6e t 2/D
Owner/Ckn4actorSignatu4 Date
Community Development Department
Building Division
y 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 ie-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: 2 eAt,5i- i `—ov'T ""�'�� Q
Job Site Address: < 9 �o /pG�'�NC',
OCAyb
Roofing Company Name:
Aplie
ant's Signature: Date: 9 /7 O
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
' REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# IrO OQ Date: F11 710
Building Address:
Owner's Name: Phone#: 2-
S5 —S9Q
�
Contr tor: p Phone#: License#:
�Lrfkk yo L —020 S
Contact: /`LAX Phone#:� — Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
V Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) )d Other(Specify) ,Qwta_Q; ,
Number of existing coverings 1 ,X Provide I.C.B.O.Report#
Ix To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job escri tionDp: /� �
AWL a.e�G e.Ce Gxe� — S• 7 �,J.F
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plan ' e t. if
there are anres ctions:
Cost of Project: Type of Cont ti : Occupancy up
/ASco. Oa r
Qty. if
A tca Fee ID Fee Description Fee Group
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�-20t7
3 3 2h