04080067 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT . -ONTRACT,OR4INF.OM
RATION :
BUILDING ADDRESS: PERMIT NO.
04080067
ATES DR
OWNER'S NAME: PERMIT ISSUE DATE
NE:
SANITARY 0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o
uo0 LICENSED CONTRACTORS DECLARATION
s I hereby affirm that I am licensed under provisions of Chapter 9(commencing lob Description
<iE with coo" )Of Division lof Buri dPr ssiuns Cade. m lice is
j iin fmLw derreet. REROOF
License Lic.a
car CONTRACTOR: TIGER ROOFING
ARCHI CTS C1.A rtT^ON
a 1 undo rend m pi ns shall located as ds
DyU
u Licensed Professional
=v,5 OWNER-BUILDER DECLARATION
Z I hens,ME.Nat 1 am exempt fru.the Contractors License Law for the
00 following moon.(Section 703 1.5,Business and Professions Calc:Any city or county
'u m which.quires a permit m emisim"alte,improve,demolish,Or repair any structure
Poor it)its issuance.also regmms the applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of the Codricmrs Limnx Law(Chapter 9 Sq.Ft. Floor Area Valuation
pro (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y Not he u exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number - Occupancy Type
not more Nan five hundred dollar(SSW). r
❑1,u owner of the property,or my employees with wages u their sole compensation,
will do the work and the structure is not intendad or offered for sale(Sec.7044,Business
3692401T—
and Professions Code:The Comoscmr's License Law does nut apply m an Owner of 00 Required Inspections
property who builds or improves daemon.and who dmesswh work himself ormrough his �®
own employees,provided that improomenta are not manded oroffered for sale.11. �ry\V(t�AW
'S the building or improvement is sold within one year ofcompledon.me owner ®a+
builder will have the burden of proving Out he did not build Or improve for pu ixse of 11 w
sled g 2004
❑ 1.as owner of the p.ptitY am exciusiyely contracting with licensed contnaors to puG 1
coosuuct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- 1'A
ceme w does not apply to an owner of property who builds or impmvu thereon.and,
who ntacu for such projects with ac,mm�mr(q licensed pursuamm me COnrxmh ���
Lk x Liw.
I am eacmpt under Scc. .B&P C for mis.uon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury ore of the following dmila lions:
❑l have and will maintainaCcrtiOcau of Conserv to self-insure foe W,rkcr's Compcn-
smio",as pmvided for by Section 37W of the Libor Code,for me ped wmance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Secmm
37W of me labor Coda,for the performance or me work far which this permit is issued.
My Workers Compensation Insurance carrier and Pulley number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the remit is Impact hundred dollars(SI W)
Or less.)
1 certify that in the performanec Of me work for which Oil permir is isaucd,I shall not
employ any pc manners,as to become subject to the Workers Compensation
I fCalifurWaT�C
Apptt� t �if'7
NOt1tiFJfO'APPL1 A :Ir.—after m king this Ccni ream oT p
bee subject to me Workers Compensation provisions or the labor Com.you most
Z foMwith comply with such provisions or this permit shall be deemed¢voted.
z CONSTRUCTION LENDING AGENCY
l-.�. I hemby affirm that mere is a construction[ending agency for me performance of
(Y, the work for which this permit is issued(Sec.3097,Civ.C.)
It7 Q Lender's Name,
(L Lenders Addrasa
a Z
U Q T certify that I have read this application and sure met the abase information is
Ls.P correct.I agree to comply with all city and county o c inances and state laws relating to
0U building construction,and hereby sumorix mprexnuthms of this city to enter upon the
�^a above-mentioned Property(Or impecuon Purinxs
,n (We,).,me to save,maimndy and keep harmless the City Of Cupertino against
h liabilities,judgments.costs and expenses which may in any wayaccom againstsaid City
U 2 in eonxgwnec of me granting of his permit.
^' APPLICANT UNDFJLSTAyDS'ANO WILL COMPLY WITH ALL N -POINT Issued by: Date
SOURCE RE AT f
Re-roofs
OrApph anU onuact are
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WilltM applicant tar future building Occupant store w handle am Intenal
as defined by 1a Cupertino Municipal Code,Chapter 9.11,and rhHeald add Safety
code.Swoon 25532(.)+ All roofs shall be inspected prior to an roofing material beim Installed.
❑Ye: � P P � Y g g
41h.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
emit
d...air contaminants dcrncd by dee Bsy Ama Air Quality Management all new materials for inspection.
District?
❑Yes fi/
gyp' u
I have mad me ha7xd"usmamnalsmquimmcnuundcrCUpwr6.95ofmc Califon r / ,•
"ice Hcalm&Safety Cwt.ftiu 505.25533.d25534.lundcaundthatllthc building
J,es not curenJy nava moan 'cep, 'bility to notify the ne"Pant of me
marrim whrnm ee, ', a, accrorcatc,raapaney, r i nature ofrplicant Date
All roof coverings to be Class "B"or better
Ownc atithori'md
age ax
Community Development
F 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDU: LAIv ^ PE � O
OWNER'S N 'cam PHONE #
GENERAL CO ACTOR: FAX #
I am not using any subcontractors: y
Signature ate
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 C ,� -DIDr
Septic Tank
Sheet Metal
Sheet Rock
® Tile
CD
ar Contractor Signature Dat
Community Development Department
F' Building Division
E .fi1; �Rw
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
SUPEkTINO 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.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: (� )�/�V S 1/1
Job Site Address:
Roofing Company Name:
Applicants Signature::'//�/% � Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
t
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Owner's Name: f S e Phone #: p
Contractor: .'rPhone#: S 6 1 l�' License#: �y
Contact: ��( � Phone#tot ( � Cupertino Business License#:
--
Aug-� Type of Roof Covering:
Existing: Proposed:
❑/Built-Up Roof ❑ Built-Up roof
Asphalt Shingles Asphalt Shingles
❑ 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 ear O w g�ti `I � W_t/p U
r�l
Residential F-1Commercial F1V v
Fire Zone: Yes ❑ No ❑ Confirmed with Pla f
6h - there are an re tctioris:
Cost of P _ �ytse of Con tion:^ � ' Occupancy cup• r
Q
A tc 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
Ll BUSLIC Business License BU]LDING