03070011 (2) CITY OF CUPERTINO
BUILDING DIVISIONPERMIT X0NTR `CT0RINFORMATION v
BUILDINGADDRESS: SIGNATURE ROOFING INC 111111 N'03070011
1-11r) 2 2MRI-I-ING RD
OWNER'S NAME: 555 OINEILL AVE, #16 PERMIT ISSUE DATE
'"E' (800) 644-7410 SANITARY NO. CONRIL10,
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j00 LICENSED CONTRACTOR'S DECLARATION
[mF I hereby affirm that I am licensed under provisions of Chapter 9(commencing lob Description
SZt� with Section]OM))af Divlaion 3ofthc Ousincss and mf ssionsC Jn dmyliccnu is
'oma in full(orce andc egl. G 6 REROOF
? Llcens��e,�CCKus 3Y Ic.
Dau
— un, °it JUL 1 5 2003
I understood my plans ahallhuudu PUMlc ,ON
>y
ge0 Licensed Profession.[ ' 1
IL®�PI^
OWNER-BUILDER DECLARATION ,
2 y 1 hereby affirm that I am exempt from the Centimeter,License Law for the BUILDING
Iv ASI VV�G
MO following room.(Section]031.5.Business and Profession Code:Any city or county
<2 LL which.4m.a IMmin to comonol, lw,.Improve.demaheh,or.,air any mocuR 462
prior In its issuame..)so stuns lheappliremot osr.uch Permit to Ole a&ignedstaument
< that he is licensed furualnuthe provisions of(be ConlmelorsLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
eta (commencing with Section 7070)of Division J of the Business and Professions Code)nr
15 Nal he u exempt therefrom and the bust for Ne alleged eumption.Any violation of 36226004 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than rive hundred dollars(5500).
C 1,u owner of the property.or my employe.with wages at Neirame compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business — Required Inspections
and Pmfessiom Code:The Contractors License law does not apply m an owner of 307 - I NSULAT IgON p
property who builds or improve&Neeson,and whereas such work himself or through his
own employees,prodded that such Improvement;see not intended or offered for sale.It. 601 — ROOF TEAR OFF
however,Ne building or improvement is sold within one yeti 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
u1c')' 603 - ROOF BATTENS
C L u owner ij ct properly,,Business s and commons with licensed convectors to
eonatma does not
ctpply to an owner
property
who
orIproves mo on.Li 604 - ROOF IN-PROGRESS
whom law coca not apply a an owner of property who builds or ant to me ConnA.and
whence Laces for projects with a conuulor(e)licensed puuvem to Ne Comnnor1
ElIme Law.
❑ I am exempt under Sec. .B&P C for his rcuon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury on of Ne following declarations:
I ham and will meinuin a Coudicam o(Cmnsenuo saf-insure rot Wacker&ComPen-
sation,.provided for by Section 3]00 of the labor Code.for Ne performenm of the
work for which Nis permit is issued.
have and will maintain Wmkeri Compensation Insurance,u required by Section
3 00 of the labor Code,for Ne performance or the work for which this permit is issued
My Workers Cent ulsa'on lmunnwe mer and Polity number art: �rs�.-A
Cartier.=C �ality No.:S 7 L"O Z' ✓moi 1✓
CERTIFICAT t OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scedon need not h completed If the Permit is for one hundred dollars(SI00)
or item.)
1 certify that in the performance or the work ror which this Permit is issued.1 shall not
employ any person in any manner sat u in became subject to the Workeri Compemation
lawa of California.Date
Applicant
NOTICE TO APPLICANT:If,afur making this Cedi Rcate of Exemption,you should
become subjeel to the Worker's Compensation previsions of the labnr Code,you..at
.J O forthwith comply with such prnvisions or Nis Permit mall be deemed revoked.
'z V) CONSTRUCTION LENDING AGENCY
t-. I hereby arms that Ncrt is construction lending agency for mc performance of
IY ti the work for which this permit is issued(See.3097.Civ.C.)
Lender's Namc
=z lender's Add.
U O I certify Nu 1 have read this application aM auto that the above inform i tun is
g4 F correct.I ague to comply with all city and county ordinances and note laws reining to
DU building construction,and hereby authorim representatives o(Nis city to enter upon the
[Ll ahove-mentioned pmPuny for impaction purlases
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Tae. liabilities,judgments.costs and expenses which may in any way accroc against mid City
U7 usconuyucnce of grinding of this Pc 't.
r7 APPLICANT U RSTAN A LL CO Y WIJH AL NL%DINT Issued by: Date ell
SOURC ET 0 1
Re-roofs
Signumc of ApplicantiComractoratm e
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building occupant sou or handle hanudous material
a defined by the Cotentin Mu trial Cade,Chapter 9.12,and the Health and Safety
oro,S aria,2ss3z(an All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes Na P P Y g g
Will the applicant or rot building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha.mous all wnumina defined by the Bay Area Air Quality Management all new materials for inspection.
i strict?
❑Yes
Ihrvmad Nehmn clusm&wHalsmquim=nuunder Chapter695ofthe Califon
currently
4 Savumhat it myrspo25534.1 so wufy to m ifthut or
doer not t'Yrenlly have a LL'mNl.Nil Il It my fCEpam1111111y b Mufy 11e OISUPNI or Ne
rtyuirtmcn lo, .Ihmy pry, «tar cwrdRwpte ara�anyy./ Signature of Applicant Date
-to�� I �} All roof coverings to be Class "B" or better
Owner. Ih nvcdagenl Dal�—
I
Community Development Department
Building Division
Sot
City of Cupertino
10300 Torre Avenue
CITY Of Telephone: (408)777-3228
U P E kT 1 A O 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 complywiththe above stated policy on re-roofing.
Homeowner's Name:
Job Site Address:
Roofing Company Name: —
Ap
icant s Signature: Date: 7 teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
t
CITY OF CUPERTINO C)
REROOF
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date: -7/)
Building Address:
Owner's Name: Phone#:
Contractor: Phone License#:
�5o599-5VgV GAG 6G 8
Contact: hone#: Cupertino Business License#:
0o_rti•4--
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
�d, Asphalt Shingles Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings L ❑ 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 (Z,
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are an restrictions: i5
Cost of Project: Type of Construction: Occupancy group:
c/ V6 Z. - 6t)
Qty. if
Applicable 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
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