03100006 CITY OF CUPEirrINO t �
CON1R?.CTOI2,INFQRMA!)Nf,
BUILDING DIVISION PER
BUILDING ADDRESS: \ PERMIT NO.O310(]006
OWNER'S NAME: PERMIT ISSUEDATE
PHONE: - SANITARY NO. CONTROL NO.
• ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION
m I hereby Affirm that I em licensed under provisions M Chapter 9(commencing Job DESClIptlOn
with Section 7")ofme
0ivo3 of Ne Business and Profusions Code.and my license is
N mm�fo.andeffect. REROOF P�IVALED
i
:MZ License Class Lie.0
! � Date GSDECL DEC 3
ARCHITECTS DECLARATION 0 2003
t I undcrsmnJ my plans.hall he aca.a public records
sa
o w GLicensed Pmfca.ional
OWNER-BUILDER DECLARATION BUILDING
i<n affirm hereby arm that I am exempt from the Contractor's License Law for the
:M0 following reason.(Section 7031.5,Business and Profssions Code.Any city or county
$� which requires a permit to construct,alter.Improve,demolish,or repair any structure
•Tin prions its issuance.also requires the applicant for such Permit to rile a signed statement
< that he is ti
icensedpursuann(beprovisionsoftheCommnLaw Sq. Ft. Floor Area Valuation
E�0 (commencing with Section 7")of Division 3 of the Business and Pmfenions Cnde)ur
4 Nat he is exempt therefrom and Be basis for to alleged exemption,Any=Of 36651003 . 00
Section 7031.5 by any applicant for a Porch subjects the applicant to a civil penalty Of APN Number Occupancy Type
not more Nan five hundred dollars(2500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
'b ill do the work.and theswnure is not intended or offered for sale(Sec.704.Business 305 — FRAME Required Inspections
and Profession.Cade:The COnuacme.LRA.Law does not apply t.an owner of p
property who builds or improves thenen,and who does such work himself or Wough his 307 — INSULATION
own employees,provided that such improvements am not intended or offered for Aide If, 601 — ROOF TEAR- OFF
' however,the building or improvement is sold within one yes Of camplction.the owner•
• builder will have the burden of proving Nat he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
Z7 as Owner of Be property,em exclusively convecting with licensed conuaciosi to 603 - ROOF BATTENS
construct the project(Sec.7D44,Business and Professions Cmle:)The contractor's Li. 604 — ROOF IN—PROGRESS
eerie law does not apply to an owner of propeny who builds or improves thecon,and,
who contracts for such projecu with a contractors)licensed pursuant to Be Commences
License Law.
❑1 am e.empt under See _ .B h P C for this mason
a
Data V I 1
RKER' O NDE TION
I hereby affirm under penalty of perjury one o c fallowing dcclar.1kos:
•']Ihaw.ndwill mainuine Ccnlficaeof Conaenuo alf-inaum for Worker'.Compere .
ation,u provided for by Section 3700 of she labor Code,for the performance of the
work for which this patmit I.issued.
❑1 have and will maintain Worker's Compensation Insurance,as mquimd by Section
37W of the lane,Code,for On performance of Ne..,it for which Nis permit I.issued.
My Worker',Compensation Insurance carrier and Policy number am:
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not h.completed If the permit is foront hundred dollam(5100)
or les..)
1 certify Not in the pednrma tcc of the work for which Nis permil Is issued.I shall not
employ any person in any manse,an As to become subject o the Workeri Compensation
Laws of California.Dae
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker'.Compensation provisions of the labor Code,you must
�Z forthwith comply with such prnvisinu or this permit shall be deemed revoked.
0
CONSTRUCTION LENDING AGENCY
I hereby aRom Net time is a construction lending agency for Ne Performance of
Y.7 the work for which this permit Is issued(Sec.3097,Civ.C.)
i1 n Lcndcr's Name
—
1yr Lender's Address
j Q 1 minify that 1 haw mad this application and snm Nat to above information is
yr f—' correct,l agree to comply with all city and county uNinancea and slam laws misting to
V building mentioned
and herebyauthonp representatives utives of this city mcmer upon the
shove.(We)agree
property for indcm inspection pmposea.
(We)agree to cast,indemnify and keep harmless the City us Cupertino against
-' N inconacejudgmenu,grassing expenses thisPermit. may in any way accmc ageinsl..id City
j in consequence of Nc gaming.folia Permit.
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
so URC REGULAT S.
Re-roofs
a 3f P Toon n out t Data
HAZARDOUS MATERIA 'DISCLOSURE'
ISCLOSURE Type of Roof
Will the applicant or future building uccup Ismse,.,handle K.Cammusnaaterisl
ss defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
code,Scenes 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant Orfuture building Occupant use cquipmentor devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
Dinria?
❑Yes �Nu
I have read the hamodo amrisla mquirem.nw under Cbn,ee 6.95 of the Cali fns /_
nim Hcal N dr Solely Code,Sccum,25505,25533 and 25534.1 undetamnd Nm if 0,lxti Wing l IL O J
do-.not cuncrttly how a ten t th it is my map.uibilbY 1.notify the rcI.Pent of the
mipown ts ichmushmpriortoiss ante.,.carer aeoratop rfy SIgD,..Ur,ofAp Kant Dale
ri� l -�o
01 Tura rizedAgcm part All roof coven to be Class "B"or better
CommW Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408) 777-3228
P E RT I N 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.
J I understand and will comply with the above stated policy on re-roofing.
N �
r Homeowner's Name: �12 � e, W LO V� �PM Owa^^]
Job Site Address: l t lM7 � "t
Roofing Company Name:
A plicant s Signature: Date: 0 ► 10 3
I C& rl-Nv I _J V� 4a el
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINR v-�—o�
REROOF 3
CUPEkTINO PERMIT APPLICATION FORM
• APN# / Date:
(� t 1 0
Building Address:
kt, SAO C O`
�d Wim.
e
Owner's Name: Phone#:
t Y\ M+ 1 %(H Ieil)
Contractor: 1,k) Phone#: License#:
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
)d Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles �7�2
❑ 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: e
1a.ec ro
Residential Z Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are an restrictions: LJ
C P ject: dpi Type of Constru Occupancy group:
Qty. if
A " li le 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
2333
zs 71
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. F �<�o
/S?o QPLAND W _- ties
U �42T1i�10 C°A °f5
i
J T
r �JoOASNAkrR�AIB .L Tom. 9 ViYTI/ rflTl�J�I�.
0 1 2003
-- Mo f b-12 t,I F E T/ LE, - n
-� )C8OW 26x6 , 6't5cW"X6 PCS
r9 PX'r 560 "S P&R sq WARD Rv: —
2"s6x/79 PCs,
NN
l2 '
4-
OPY
0
j PR
RDANCE W UE 00
Y0 ODE Lir
7 x io F. "4S_. '� A E
aD---
icatio ns Mu '
.X ��� •— and it is uAr t
alteration9l
w and
b
H Tha ala ,,:in® tnis plan and speafications'
aNAll OT be held to permit or to be ar
of the violation of any provisionr<
Ordin_®_nce or Stets law,
8 7 6 5
nicgaui ran rage i or l
Seven Springs Owners Association
Application For Approval of"CATEGORY C "Architectural Change/Addition
• Category C Modifications are exterior modifications with no changes to the original building structure or floor plan. All
roofing,siding,or window material change,or exterior paint color change,or addition of a roof attic fan or tubular skylight, .
fall into this category.
To: Architectural Control Committee
Subject: Request for Approval of Proposed "CATEGORY C " Architectural Change
PLEASE PRINT THE FOLLOWING INFORMATION
Name: 77e n y (ti'ti Address: //S'7 C,inLA (JD ( t1 �y'
Home Phone: 4'c F - 7 7 7- ?4 k'X Work Phone: ce�_�- te,a-/<d.
Homeowners'Signature: Date: —5-/-/�
Description of Proposed Cha ge: rX
1)Paint color change: V L�
New Exterior Siding Color t i t /fit '
New Exterior Trim Color t.li r
2)Roofing Material change
New Roof Material i ld e%g61 Cclxc , Ve —%✓0',11er1' x'10
3)Siding Material change & r ' ver""'`•'4 .
New Siding Material /V A
Which sides are you are changing material (front,back, left or right,or all?)
4)Window Material and Design change
New Window(Manufacturer, Style No.,and Color)
5)Adding a roof attic fan or tubular skylight 7lv�D
• New attic fan(manufacturer,Model No.,and Color)
Please attach detail information regarding the attic fan. ApplicdItion @ �t i4l nsion and its location on the
roof.Please include detailed drawings,specifications,and product brochures if available.
++**++++****+*+**+*+******+********+*******+***+tvY+a+****s—
ARCHITECTURAL CONTROL COMMITTEE/BOARD ACTION .
Approved � Approved Pending
Denied_ Denied Pending
Architectural Control Committee/Board Comments:
Architectural Control Committee/Board Signatures:
gate: 91
http://www.cupertino7springs,org/Catagory_C_Application.html 9/17/2003
�o•'�,. Aared'ADy
ICB0 Evaluation Service, Inc. American=be,'alStande0arthedslnstlMe
5360 WORKMAN MILL ROAD' \ WHITTIER, CALIFORNIA 90601-2299
A.subsidiary corporation of the International Conference of Building Officials
ry '= EVALUATION REPORT, ER-2656
Copyright 0 2000 ICBO Evaluation Service,Inc. Reissued June 1, 2000
Filing Category: ROOF COVERING AND ROOF DECK CONSTRUCTION-Roof Covering (202)
EXTRUDED CONCRETE INTERLOCKING ROOF TILES water damming.Cracked or broken tiles must not be installed
MONIER LIFETILE LLC or allowed to remain on the roof.
7S7IRVINE,
IRVINE CALIFORNIACENTE2618-RIVE 2.2.2 Sheathing: Sheathing must be.structurally adequate
IRVINE, FORNIA92618-2930 to support the loads involved.At a minimum,spaced sheath-
1.0 SUBJECT" ing boards must be nominal 1-by-6 lumber spanning a maxi-
mum of 24 inches (610 mm). Solid and spaced sheathing
Extruded Concrete Interlocking.Roof Tiles;.Roma, Classic must be fastened in accordance with the code.
"100,"`Homestead, Mission 'S,' Shake, Slate, Split Shake, 2,2,3 Underlayment: Tiles installed on roofs with slopes
Split Slate, Country Shake, Country Slate; Country Split less than 2l/2:12(21%slope)are considered decorative only,
Shake,Country Split Slate,Cedarlite,Espana,EspanaTejas, and must be applied over an approved roof covering,subject
Capri,Villa, Sentry Classic and Traditions. to local building official approval.
i 2.0 DESCRIPTION On roofs with slopes of 21/2:12 (21% slope) to less than
2,1 Materials: 3:12.(25%slope),an approved built-up roof applied in accor-
dance with Table 15-D-1 of the code oran approved single-ply
j 2.1.1 Regular-weight Tiles: roof membrane assembly must be installed prior to installs-
The extruded concrete roof tilesere'interlocking.elements tion of the tiles.
having the dimensions and configurations shown in the ac- On solidly sheathed roofs with slopes of 3:12(25%slope)
companying table and figures.Accessory,tile units are avail- to less than 4:12 (33%slope), underlayment may be as de-
able for ridge, hip and gable areas,.The regular-weight tiles scribed ihit6t section-for-roof:slopesiof 21/2:12(21%slope)
are composed ofportlandcement and selected sand'aggre- to less th�an9:'l2'- slope ),oimaybeasingle layer ofType
gates.The mix proportions are accurately maintained to en- 90, grariuiar }}tti f,aax@@d, asphalt roll r offing, or two layers of
sure tile production in accordance with the specifications.An- Type 30 fait fig tac shi 16 fashion, or other approved
chor lugs, located on the underside of all tiles except single-plysystemsinstaliedin acclancewiththegodeoran
J Cedarlite,overlap wood battens,purlins or spaced sheathing ICBG :evaluation report. yy�f�, � �n�y""iiRd
for anchorage in the plane of the roof. Holes are provided in Over solid sheathf q,-dh roof�s�_ the sl peySLof 4v 12 (33%
each tileforfasteningwhere required bythe installation.Inter- slope) or greater,runderlay"ent(must ha�onef layl of mini-
lockirigribsareprovidedonthelongitudinaledgesofthetiles mum Type 30fe1teithercoi ;5)MgwIthW§i Ij226orrecog-
to restrict lateral movement and provide awater stop.In addi- nized in an ICBd ES evaluafion report,and must completely
tion,transverse bars are provided on the underside to serve cover the decking.
j as weather checks.Mineral coloring oxides,areeitherapplied When the tiles are installed over spaced sheathing,the un-
to the exposedsurface inacementitiousmaterialormixed in- derlayment must comply with the ICBO ES Acceptance Crite-
teg rat ly with the tile mix to produce a through-colored product. ria for Concrete Tile Underlayment on Spaced Sheathing
The tiles are cured to reach,required strength before ship-
ment
hip- (AC08).The underiayment must be draped over the rafters,
menta See Table 1 for product designations,dimensions and with a 4-inch(152 mm)headlap and a 6-inch(152 mm)side-
installed weights.See Flgure,1 for file profiles. lap.
2.1.2 Lightweight Tiles: Duralfte tiles are manufactured in Underlayment must be lapped over hips and ridges, and
the same mannerandsize.andwiththesame profiles,asreg- lapped or laced through the valleys. Hip and ridge nailers
ular-weight tiles, but the tiles are comprised of portiand ce- must also be covered.
ment,lightweight aggregate and proprietary Ingredients.See See Section 2.2.9 for application of underlayment in areas
Table 1 for.product dimensions'and installed weights. subject to roof Ice buildup.
2.1.3 Cedarlite: Cedarlitetiles are manufactured in the 2.2.4 Battens:
:.same manner as regular-weight tiles, except they are com-
prised of pordand cement,lightweight aggregates and propri- 2.2.4.1 Cedarlite Tiles: Battens installed for Cedarlite tiles
etary ingredients,and have a wood shake appearance and must be nominal 1-by-3 wood.The battens must be fastened
•i,� flat backside. as described in Section 2.2.4.3,and spaced at 10 inches(254
mm) on center. The top edge of the Cedarlite file must be
22 Installation—New Construction: . aligned with the top of the batten.
2.2.1 General: Installation shall be in accordance with 2.2.4.2 All Other Tiles: Battens are required on solidly
T., Tables 15-D4 and 15-0-2 of the code,except as noted in this sheathed roofs with slopes below 3:12 (25%slope) in order
report.Care must betaken to ensure both horizontal and ver- to minimize membrane penetration,and above 7:12(58.3%
tical alignment on the roof.Foreign particles must becleaned slope)to provide positive tile anchorage.Battens must befas-
y`. from all interlocking areas,to ensure correct fit and prevent tened either with corrosion-resistant 8d common or box nails
Evq/aotion report;offCBDEvaluatioreService,Inc-,are issuedwlely toprovide informationto CfassA membersofICBO,udliVairthe code upon which thereport
�isbased.Evaluwion reportsamnot to be conamedwmp"sentingaeslhetiuoranyotherawibutesnotspecifwallyaddresrcdnorw"endosremenl orncommen-
dation for iise of the subject!-Port.
This report is based upon independent tests or.othertechnical data submitted by the applicant.The ICBOEvuluation Service,Inc.,technical staffhas reviewed the
test resubsand/orotherdata,buidgesnol possessteo foci itiesto make on independent verification.There is no warmntybyXBOEvaluation Service,Inc.,express
orimplied,wtoany"Finding.^orot%ermatterin rhe report orasbany pmductcwered bythe report.Thisdisclaimerincludes,butisnot timifedlo,merchantability.
• - 1
. SALES OFFICES NATIONWIDE
t.-
PHOENIX'•ARIZONA
i
L
p `11tTeC�1111Ca1 GILROY CALIFORNIA '
g LATHROP•CALIFORNIA
• STOCKTON•CALIFORNIA .
y � � -
j RIALTO CALIFORNIA
" DENVER•COLORADO
BOCA RATON t FLORIDA.
CH-.FLORIDA
IDA
POMPANO BEA R
LAKE WALES• FLORIDA
CeC arLite : Size and Coverage " Weight in Place i Available Trim KAPOLEI•HAWAII
r. Individual tile nominally 13 1/4"x 13". Installed weight per square approx.560 lbs.,. 7 90°Rake. Hip and Ridge Tapered Eave Starter KANSAS CITY• MISSOURI -
' ., At 3'minimum headlap,approx:120 field ties HENDERSON • NEVADA
will cover.100square feet of roof,area" KATY•TEXAS
TACOMA•WASHINGTON
Tile is an internationally recognized premium'roofing
product providing the qualities of timeless beauty;
DllIaLlte Size and Coverage; Weight in Place Available Trim fire safety and durability, setting the standard for
*�, 66
roofing excellence.Automated precision production
ES ana Individual tilenominally 17"x 12-3/8 Installed weight per square approx 590 lbs �- Capri Trim Hip Starter Capn Apex Capri 3-Way techniques enable MonierLifetile to be the affordable- -
Espana
3"minimum headlap,approx.89 field tiles .alternative with an extremely low lifecycle cost.. .. . -
Will coJer:100 square feet of roof area." o
" Code Approvals:Complies with all building codes,
-
including n
• d but of limited to ICBG SBCCI and SFBC.
9
O .O ICBO#2656. • ,
Nordiem California Capri Trim- . Hi Starter Ca n" x Ca n 3 Wa t: Easily y passes Class A Tests to
Villa P P P Y
08 and UBC Standard
"Individual tile nominally 16-1/2"x13".. ,•Installed weight per square approx.580 lbs. � � - ;�
152.
•� - _At 3' minimum headlap,approx.90 field tiles ez aw Areas: Passes Freezing
- P PP - -
.. - - - -
/\�
and Test of ASTM-C67.
will cover square feet of roof area.
... .��
Disclaimer. T -ria - w
• he ted colors she n m this
r P
Southern California
brochure may vary.from actual current file colors.
T v n
0
1 "200
3
.Individual file nom Wally 17"x 13" . Installed weight per square approx. 5801bs. � - Before making a final selection, be sure to review
At 3"minimum headlap,approx:88 field tiles actual tile.samples and roof installations. Please
B
Y
will cover 100 square feet of roof area. —� — contact your local sales office for further assistance.
. Installation: Please consult current printed' . +
individual tile nominally 16-1/2'x 13'. Installed weight per square approx. lbs. 90°Rake 3-Sided Ride 3-Sided Hi Starter MonierLifetile Installation.Guide for application '
..'Saxony - - 9 P Apex 3&4-Way PP .
..y4 At 3"minimum headlap,approx.88 field tiles recommendations..
+ Shake will cover 100 square feet of roof area. - - I \�I I�/I The above technical specifications do not constitute ,
• _ _ _ .- ���BBB ���, ////// / a warranty by.MonierLifetile.The only applicable
- I warranty with respect to this product is the Limited.
P
- - Lifetime'Product Warranty (fully transferable,
Individual tile nominally 16-1/2x 13'. Installed weight per square
p q approx.596 lbs. I 90°flake 3-Sided Ridge 3-Sided Hip Starter Apex 3&4-Way tion-prorated)contained in MonierLifetile's product
-
At 3"minimum headlap, approx.88 field tiles literature dated most,recently prior to the installation
Split Shake. will cover 100 square feet of roof area. \\ of this product on the owner's roof.
®MonierLifetile'
'Changing the way people think about roofs.
Individual file nominally 16-112'x 13'. Installed weight per square approx;596 lbs _ 90°Rake 3-Sided Ridge 3-Sided Hip Starter Apex 3&4-Way. - • "
At 3"minimum headlap,approx.88 field.tiles r A^� m�mne�°r
Slate will cover 100 square feet of roof area. \\ ""� yea - �- `� CJI - �- F•FILE -
-. @20M Moniie'r't-iifettiille'R'RR2o43 02103
CYCY OF CUPERTINO
BUILDING DIVISION PERMIT r`CONTRACTOR INE0RMATI,ON
BUILDING ADDRESS: PERMIT NO.
03100006
11 -7n TTPTANT) WY
OWNER'S NAME: PERMIT ISSUE DATE
L: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
i u C I theories from Out I am licensed under provisions of Chapter 9(commencing P
.mbw with Section 70M)of Division 3 of NC Business and Professions Code,and my license is
s
in
i q force antlcffct.i Luterse Class
Lie.If REROOF
Dae Contractor
IM DECLARATION
t Q
; ARCHITECTS
I understand my planamell be used u public me.,&
6 DEC 2UUV
&Qt, Licensed Professional
I<5 OWNER-BUILDER DECLARATION pq�
q 1 hereby affirm Nal I am exempt from the Contractor'&Licenser Law for the ��'�'N�M
-O O following mason.(Section 7031.5,Business and Pmfcssions CWc:Any city of county
SQ which requires a permit ht construct,eller,improve,demolish,nr repair any sternum
ZY Prior tuns issuance,also.,dosdus,licam Warmth permit h flea signedmicursm
x< that he is licensed pursuanttoilia previsions ofthe Contractor's Licens,Law(Chapter 9 Sq. Ft. Floor Area Valuation
LI-O (commencing wi inna
Section 7")o(Division 3 of the B usie and Professions Code)or
ey that he H eacmpt themfram and the basis for the alleged aempdon.Any violation of 36651003 . 00
Section 7031.5 by any applicant for a permit subjects the appficant to acivil tonally of APN Number Occupancy Type
not mom than rive hundred dollars
0 I,as owner of the property,or my employees with wages as their sale compensation,
will do she work and the anchor is not intended or offered for sale(Sec.IDH,Business 3 05 _
and Professions Code:The Communes License Law doll not apply h sen owner of Required Inspections
property who builds or improves themon,and whodoessuch work himself or through his 307 - INSULATION
own employees,provided tont such improvement.;we not intended muttered for sale.If. 6O1 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
cL as owner of the propeny,am eaclusively contracting with licensed contractors to 603 — ROOF BATTENS
conanct the pmjeci(Sec.7044,Business and Professions Code:)The Contractor's Li 604 — ROOF IN-PROGRESS
cense W w duce not apply to an owner of property who builds or improves Nemon,and,
who contracts for such projeeta with a contractor)licensed pursuant to the Contractor'&
License Law.
0lamu rcpt under Sec .B A P C for this recon
err - Date O 1
RKE i N DE ION
I hereby affirm under penalty of Perjury one o fallowing declarations:
❑I have and will maintain a Cenificum of Conserv to selbinsure for Worker'sCompcn-
moon,n provided for by Section 37W of the Labor Code,for the Performance of the
work for which this permit is issued. .
0 I hate and will maintain Worker's Compensation Insurance,as required by Section '
37W of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number am:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mr.secdnn need not be completed If the Permit is for one hundred dollars(SIM)
or less.)
I cenify ilia,in the performance of the work for which this permit is ounce.I shall not
employ any person in any manner an as to become subject to the Workeri Compensation
Laws of California.Data
Applicom
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Cnde,you must
Qforthwith comply with such provision or this permit shall be doomed revoked.
�2 CONSTRUCTION LENDING AGENCY
I hereby affirm Net there is a construction lending agency for the performance of
X> the work for which this permit is issued(See.3097,Civ.C.)
QLender's Name
z Lcndera Address ^ _
;)Q 1 cenify Nat 1 have read this applicainn and state that the above Information is
Z. F bonding I agree to comply with all city and county oNine,s of and cute lawn totaling e
buildingconstruction.proand hereby forimauthon prepmsenutiwofthiuitymcnmrupon the
Y ehovc(Wei agree to orlysave fodemnify opurposes.
ti D.
(We)agree to,cove,indemnify end keep harmless the City someone
Cupertino gainer
h inconaccumcc jof udgments,costs and orpcnsesmit. may in any way¢ctw again&said City /
J z APPLICANTeUN EfIANDSthis ANDrWILL COMPLY WITH ALL NON-POINT Issued by: �(4 Date
SOU C NT UL S. . I S
p lean ct etc
3 Re-roofs
HAZARDOUS MATERIA DISCLOSURE Type of Roof
Will thdapplicam or forum building wcu tamer or handle hamNun material
u defend by the Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety
Code, r IYes �No
25532(&)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye
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
haatdmo air contaminants as defined by the Bay Area Air Quality Management -
D'utrict? all new materials for inspection.
0 Yes �Ntr
I have mad the haranlnus materials requirements under Chapter 6.95 of the Califon O 1 1 1
Wt Health @Safe[,Code,Secduns25505,35533 and 25534.1 understood his l fore building IL t IL O
does not canendy hast a ten) h that II is my reaponsihility or Wiry the cartiont of the
rerprone nvich Eich bE t poor or sync ora C.eifeWe of 0.cuPanrty.10 Sign ur O Ap can[ Date
Oriaedagem ( D,te All roof coveri to be Class"B"or better