03050014 (2) CITY OF CUPERTINOr ^a4�'w .�u '.-:
BUILDING DIVISION PERMIT ,CONTRACCTOI2INFORMATIO1Va
-
BUILDING ADDRESS: PERMIT NO.0 3 0 5 0 0 14
770 QRQrPANnP. DT
OWNER'S NAME: PERMIT L^SQEj)A'r§ S/2 0 0 3
ALAR UU7�� U
NE: SANITARY NO. CONTROL NO.
ARCHITEC 13PIGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
ilo0
LICENSED COMRACIOWSDECLARATION Job Description
1 hereby&(firm that I em licensed under provisions of Chapter 9(commencing
with Section 7000)of Division]of the Buainessand Professions Code,and my license is
'^ in full fomeand e epi, Z. REROOF
Liccn A Lk.g
tate cants "nECONTRACTOR: CONLEY ROOFING p p to,®
ARCHCPS DECLAR FINALE
�i 1 understand my plan,shall W used As public=am,
6
A.
Licensed Professional OCT 2 9 2003
G OWNER BUILDER DECLARATION l
+� I herebynaso .(ileo that 11. exempt from to Contractors Co License Lawcity
for the
`oO followingreason.(Saito]cost Business, erandfhafeedoli Code:Any tiny Scounty
$ which myulmu• .&koro cores the &Iter,Improve,demolish. fl opals'ed stmcmm
Z� gitonins Wuadpursuantto to p vI.I.ient for each C.At.nitro.a signedstatement
t—�
that(comEMUM
mencing
sccenseJ pursuant 700)of Divlonsnf Nehe Buscmr'and Pramaw(Chioter9 Sq.Ft. Floor Area
(commencing with Scml.n]000)of Division?of the Business andPr.fruions Cook)of
— Na he Is exempt therefrom and to basis for the Alleged exemption.My violation of
Section 7D71.5 by any applicant for a permit subjects the Applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars(5300).
❑I,as owner of the property.Anmy=plays=with wages As their role wmpewtion, 36218018 . 00
.111 do the work,and the suunurt is oat intended or offered fmssle(See 7044.Business Required Inspections
and Professions Cade:The Conbaetors License law data at apply m an awner of ,4 n F q P
progeny who build,At Improve dRme
on,and who doauch work himselfor through his -e- mom--F-t�-rfiiE
own employee,provided than such improvements Are not Intended or offered for sak.If.
however,the building or improvement is said within oro year of completion.the owner.
Wilder will lose the burden of moving cut he did not Wild or improve for purpose of 601 - ROOF TEAR OFF
ale')' 602 - ROOF PLYWOOD NAIL
❑I,As owner of the property,am exclusively contracting with licensed comrsco rs to G f)1 D!1(1T' La D TTL'TTO
construct the project(Sec.7004,Business and PrefaalOns Code:)The Cont acts'Li.
cense law data not Apply in An owner of property who Wilds or improve themon,and, 604 - ROOF IN-PROGRESS
who contra forsuch projects wit ac ounscor(l)licensed Pursuant mthe Con1101m01`8
License LA..
❑Ime.aempnunder Sec ,B&PCfm Nbreaon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hent,aRnn under washy of perjury one of pre following declarations.
1 haw and will maintain a Ccoffm to of Consent be self-insure for Worker's Cooper.
sation,a provided for by Section 37M of the Labor Code,for Ne performance of the
work for which Nis permit is iawA.
have and will maintain Workers Compensation Ins. mutt.a required by Section
of to Lamor Code.for to performance of to work for which this permit is iawd.
my,
y Workers C mmeryatlon Innetca crPoi Policy
number eco
Cart er.
CERTIFICATE OFEXEMPI70N FROM WORERS
COMPENSATION INSURANCE
(This section wed not W completed If the permit Is(ortw hundreddonars($10()
lir(Cie)
I certify Na in rite performance of the work for which Nis permit 4 issued.I shall not
employ any Fithian in any manwrso a to become subject to the Workeri Cainpenadon
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If.after making this CcI itieam of Exemption,you should
Wrome subject in the Worker's Commusation provisions of the Labor Coda you must
,J O (oMwith comply with such provisions or this permit MAN be deemed hawked.
z CONSTRUCTION LEN AGENCY
I beauty affirm Out Nem is A cossetnletlnn lending Agewy far the performance.(
C 7 the work for which Nls permit 4 issued Sec.7097,Civ.C.)
fS1 Q Leaden Name
6. Lenders Addma
V Q I'c' Nal 1 A. W Nis Application and sate Nn Ne&how informau.n is
IL — At I.I ague m cam ' with all city and county ordinances and&taro hues m4ting It
QU builtling erne-.. ,And hereby authorise represenutiwa of Nis city to cmmrupon Ne
r
show. done roperty far inspection purposes.
(Wit) tee m ave,indemni(Y and keep hannlea the City of Cupertino against
rag liabilille,j gmenu.cosu and expense which may in Any way secret against said City
U,Z', in consequence of the granting of Nis permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signaum of ApplicanVC.nDam
HAZARDOUS
S MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant a ost ham
udaua ateriel
a dcOned by the Cupertino Municipal Cade.Chapter9.1 and r 9.13.and Ne Health and Safety
ID,�WkO
dc Scene.85784)7 All roofs shall be inspected prior,to any roofing material being installed.
0Ya �j4a
Will Ne applient or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haerdnu£air contaminants u defined by tiro Bay Area Air Quality Management all new materials for inspection.
'
❑Yea 'B,tfo
Ihacmad Ne c,Sccd smamdabmqulomenuundcr Chapted LhaifNe Wilding
far-
Hnot &Safety am a wasth, 8t it Ism raru1857a.1understandNoteup Wildingo not curenllyhow a mnan4 WI it u my responsihilily b notify aro occupant of Ne
.1 u.�'"hm`Z%Im zlauAnceAf.C=rtete.fOw.pancy. Siflicant Date
^^ All roof c erings to be Class"B"or better
ner or authonved&gam Date
r
Community Development Department
Building Division
City of Cupertino
r .1.' 10300 Torre Avenue
CITY OF Telephone: (408)777-3228
C U p E kTI` , 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 Y4"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: 64 l A ✓ O vv^
Job Site Address: -70 0 eO 5 VAI
Roofing Company Name:
A plicant' Q. Date: �-
\�lJrSliItiDCX1
r
Greg eel '
Building Official
Revised 1/30/03
Printed an Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Ad e : n
(01/16 e A-%,.
Owner's N 11"x'ne0, ( K �\ Phone j2 5 - -2-Y3 --)—
ContractPhone#: License#:
Ev-�- OSrS -b Sr 3 L 6 3002
Contact: Phone#: Cupertino Business License #:
ti4 o1r o 6��'Z
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles -e' 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:
-
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning t. if
there are astrictions:,
Cost of Project: l Type of C struction: O up y gr
o /
0 tJ t/
Qty. if
Appliqfibli ) 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
t
A
2/ 7 �-
2 7 ` �