03110046 (2) CCPV OF CUPEWMNO
BUILDING DIVISION PERMIT CONTRACCTOR INFORMATION.
nmLnlrvc ADDRESS: HENRY ADELMAN PERMIT"003110046
OWNER'S NAME: PERMIT LSUEDATE
Ahk HENRY ADELMAN 11110/2003
70NE: SANITARY NO. CONTROL NO.
ITE-CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI4
! LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am hecnsed under provisions of Chapter 9(commencing Job Descrl on
DivipWiaaorce and cffea. REROOFP1■VALMM
i' Class Lic,x
Contractor
ARCHITECTS DECLARATION f DEC ] /yoo3 rc< I understand my plans shall W used as public records C ILII J C
JyU
s in r LiccnseU Professional
`O g Oar I wo exempt
I,DECLARATION BUILDING 1 a q 1 hereby affirm ohm 1 1, [Bumps from to Contractor's o License Law for the v N�a
00 followhich re rcamn.Permit
i ]retro Business and Professions Code:Any city or county
<$in which xqus u n permit re cowron,alcor,improv,demolish, fie pair any structure
mment
in prionnitsiavuancc,alsorcyuiresthcapplicamforsuchpermitmhlcasigncdsutcmcnt 4000
cso that he is licensed pursuant10IMProvisions oftoContractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
rs- (commencing with Section 20(0)of Division]of she Business and Professions Cork)or
Nat he is exempt thcafrom and the basis for the alleged exemption.Any violation of 34230022 . 00
Section 703 L5 by any applicant for a permit subjects Ne applicant o a civil penalty of ApN Number
not mate than five hundred dollars(5500). Occupancy Type
El 1.se,owner of the property.or my employees with wages as their sole compensation,
will do Ne work,and Be sMal is not imendN or offered for sale(Sec.4Udd,Business
and Profccsinrs Code:The Cnnuazror's License Law does nut apply m m no,of Required Inspections
progeny who build&or improves thereon,and who doessuch work himself or through his
Own employees,provided that such improvements see not intended or offered for sale.If.
however.Ne 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
sale.).
❑I,as owner of the propeny,am exclusively contracting with licensed central to
Carl the project(Se,707 1,Business and Profession Code:)The Conuacmr's It.
comm law docs not apply to an owner of property who Wilds or improves themon,and
who contracts for such projects with a cenuacmr(s3 licensed pursuant 10 the Contractor's
License law.
❑la a Landers B&Pcfor x onn
O n D e_ /
.K.RSCOMPENSATIONDECLA N
I hC.OYZ.under penalty of perjury one of Nc following declarations:
1 have and will meinuin a Cenifinm of Camera to self-insurt for Worker sCompcn-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3900 of Use Labor Code,for But,performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF E%EMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars(S IOD)
or less.)
I certify thm in Lhe pelf ancc of the work for which this permil is issued,[shall not
employ any personi man er as gY�uye[Qon ubject m'Nodetd Compchishon
Laws ofC l'f IP 4'� /(iYA//rl
Applieam
NQTICjs Tb AFPLICAV ,after making thi&Certificate of Exemption,you should
bee ubject to the Worker's Compensation previsions of the Lahr Cock,you must
�z forthwith Comply with Inch provisions or this Permit staff he ducca d revolo d.
zCONSTRUCTION LENDING AGENCY
I hereby affirm Nat Vert i&a consuvetian Lending agency lot Ne performance of
x Ne work for which this permit is issued(Sec.3191,Civ.C.)
SQ Lender's Name
z Underi Address
J Q I certify that I have read this application y Ordinances mm that the Shoes information is G
L5. cortengaraeto tcomply withal]city Sod countyivesOf and City
lColruponte
V buildithavengconswctiol and for cbyamhonprposexmatirts Of Niscity Lo Color upon the
} a. algae-(Wei ntidogre to save findompet'y anpurer,hu
F„z (We)agree hi sew,indemnify and keep harmless the City of Cupertino against
0, liobi litin,judgments.costs and expenses which may in any way income against said City
V z in consequence of the gaming oft sPermit.
'—' APPLI UNDERSTAND D WILL COMPLY WITH ALL NON-POINT Issued by: Date (f
R 10
t
nater[of plican an actor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser future building C.Pair store ter handle havudou&material
as defined by the Cupeninm Municipal Cod,Chapter 9.12.and the Health and Safay
Code,Section 25532(a)7
❑Yes 9Nu 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
it hrozndous air contaminants as dcfncd by the Bay Area Air Quality Management all new materials for Inspection.
x nor
❑Yes XNO
1 have mail Use hmadous materials requirements under Chapter 6.95 of dm Califil �
is Health&Safety Cade.Saeomean, 2a,it i 2my r it 25534. undumtand thm cupot building /�Q doesnot curt tly haw a¢nam at it is my responsibility Lo nastily Lhc occupxnL of the
repair which must Nlssuamcc ofa Ccdfca¢of Oce ancy.
l/ Si nature of pplicant Dale
Owner ream racdagen „e All roof coverings to be Class "B"or better
1. (Check one) I or my immediate family (parent,spouse or child)will perform
A. = All the work authorized by this permit RE
'VE
B. A portion of the work NOV 1 0 2
CNone of the work
If B or C is checked, complete 2 or 3 below. BY.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion.of the work (complete section below)
Contractor Address/City. Phone # State License# Type of work to
be performed
• 3. I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(rev se side).
Property Owners Signature: Date: O
Job Address: Permit# 6 O
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Devarhnent.
Community Development Department
Building Division
City of Cupertino
10300 Tone Avenue
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
UPEkTINO
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: LfE>141 4��
Job Site Address: /,O_;?3(� 15L IWO
Roofing Company Name:
A Date:41
Greg eel
Building Official
Revised 1/30/03
CITY OF CUPERTINO 3 �6
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN # 2— 3 0 o Z-2 Dat- /D D
Building Address:
Owner's Name: Phone#:
Contracto : Phone#: License#:
Contact: Phone#: �D Cupertino Business License#:
C 1
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles k Asphalt Shingles
A 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:
i�FXdI4; WMV s 4K &&82F tW17_f COX PG WZ 0 X
Residential z Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Plann e t. if
there are anrest ' tions
Cost o oject 45�— Type of Co t Occupancy gro
Qty
A 'ca 1 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