05100032 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Ct1NTRACTORINFORMATION:
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT No.05100032
10426 AVENIDA LN
OWNER'S NAME: PERMIT ISSUE DATE
JASON WU 125-B GROBRIC CT 10/07/2005
NE: SANITARY NO. CONTROL NO.
(707) 864-5557
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIPCr PLUMB MECH
(� 0
.00 LICENSED CONTRACTOR'S DECLARATION
m❑ I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�IW with Scmion7WN)of Division Sof the sirlctt and ProfcslsCodc.an ylicenu is
ca„ mranmtreanaerr tC39 REROOF-T/O SHAKE, INSTALL COMP. SHINGLES
,,4? Licen C
ARCHITECTS DECLARAION
ye¢< I undersand my plans shall W used as public trcnrds
yU
S C y Licensed Professional -
g OWNER-BUILDER DECLARATION
1,,:5
P I hereby affirm that I am exempt from the Contractors Liccnu Law for the
00 following reason.(Section 703 1.5,Business and Professinm Code:Any city or county
K$ which requires a Permit to consumer,alter,improve,demolish,or repair any structure $10000
prior In its issuance,also requires the applicant for such Permit to file a signed statement
ExC that he is licensed pursuor...heProvisions ofthe Contractor's License aw(Ch.,Ir,9 Sq.Ft. Floor Area Valuation
,,-a (commencing with Section 7")of Division 3o the B umncss and Professions Code)or Cb��
that the is exempt therefrom and the basis for the alleged exemption.Any violation of 'v
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r 4Rl s• Occupancy Type
not mom than five hundred do]]..(SSW). (�',
I,as owner ofthe n, " s.
❑ property,o my employees with wages as their sole compensation, � % �"
will do the work and the structure is not intended oroffemtl forsake(Sec.7044,Business e
and Professions Cade:The Contractor's License law does not apply m an owner of Required Inspections �¢
property who builds or improves themon,and who docs such work himselfor through his tiv ill',j$
own employers,provided that such improvements arc not intended or offered for sale.If. 400 IIF / 3'
however,the building or improvement is sold within one year of completion.the owner. !p/p`
builder will have Ne human of proving Nal W did not Wild or improve for purpose of
..'ai
❑1,as owner of Ne property,am exclusively eonwcting with licensed conuacmrs to 4V ,
construct the project(Sec.7044,Business and Profusions Code:)Din Contractor's Li-
cense law docs not apply an an owner of property who builds or improves themon,and,
who contracts for such projects with a contrutons)licensed pursuant he dte Contractors
License law.
❑1 am exempt under Sec. .B&P C for this..on
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of IW following declarations:
1 hxro and will maintain a Certificate of Consent m self-insure fm Workers Compen-
sation,as provided for by Section 37W of the labor Code,for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
7W of the labor Code,for the performance of the work for which this permit is issued.
My Work rete Compo in:1lnaunnes canicpnd Policy number aa:
Cartier. gl•L1G5•f� l]gJ/.�a_f--Um-ocy No.: I Z-1 3
CERTIFICATE OF E%EM MON FROM WORKERS'
COMPENSATION INSURANCE .
(ibis section need not W completed if the Permit is foronc handrctl dollars($100)
ar loss.)
1 coni fy that in the performance of to work for which this Permit is issued,1 shall net
employ any person in any manner seas w become subject o do Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnifinm of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code.you most
.J z foMwith comply with such provisions or this Permit shall W deemed revoked.
Z ` CONSTRUCTION LENDING AGENCY
'rt Ihereby affirm Nat them is a constiunion lending agency nor the Performance of
LYi 7 the work for which this permit is issued(Sec.3097,Co.Q
(y A Lender's Nam.
az Lenders Address "
V Q 1 coni!,that 1 have read this application and sate shat she above Wrono.lum is
It, F' control.1 agree in comply with ail city and county ordinances and state laws relating to
0V building construction,and hereby authorize representatives ofthis city to enter upon Ne
W shove-momidgm propertycosts
for
andexpenses
peNon Purposes.
gy (We)agree to save,indemnify and keep harmless On City of Cupertino against
F.p1 Iiaconsequenc offs,coarsing fifth esmit. may in anyway accrue against said City
C)z inconsequence Pfthe griming�o�f fifth permit.
'-' APPLICA NDERST�ppNy�/";+f+D��WILT J OMPhY WITH ALL NpN.POINT Issued by: Date (f- 61g"
SOURC EGULA'1101 c �Q /
(/�l Re-roofs .�
Signorine of Applicamu Commcmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or room building occupant smrc or handle havardous material
as col mod by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
arc,Scaias 2SS32(a)? All roofs shall be inspected prior to an roofing material being❑Yea P P Y g g installed.
Will the applicant or future Wilding«ca ant use. If a roof is installed without first obtaining an inspection,I agree to remove
PP s v yainmrm or devices which g
mn'o
it havamous air eonuminanu as defined by the Bay Arta Art Quality Management all new materials for inspection.
District? I
❑Yes Iyywv—
I have mad the haaamnus materials requirements under Chapter6.95 of the Cahoon.
nia Health&SafetyCode,Seeduns25505,25533 ond25534.1 understand tharifthe Wilding �a l
gore not cumcntly nave a tenant that it is my rcsponsiM1ility to notify the mxuP.,of the '^' �- /d( 7(t� -5
Gov
mquitrmenu h mm:rxmeypr;n aanc.pr crrdrgteprorfujan ./� Signature of Applicant Date
�•/ .,... All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: / PERMIT* d S/OU O Z
OWNER'S NAME: a.a.g W PHONE # 3 3 -3S 71
GENERAL CONTRACTOR Q FAX#
I am not using any subcontractors:
Sign'afure Date
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
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ola� v ems- - ,ps
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E IST I N 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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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.
pl
Homeowner's Name: �1" " Li,
Job Site Address: /C7 Ll Z�p o
Roofing Company Name: �Zq L m• _ /r�/c
Applicant's Signature: Date: / 7/0_s
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO cs�
REROOFCITY OF
D� 3
CUPERTINO PERMIT APPLICATION FORM
APN # .3 4 7-, 4S 3 v Date:
Building Address:
Owner's Nam ) Phone#: a 1� 3
Contractor: Phone #: License #:
OLcP
-7 ?2- 300 622.73 /
Contact: Phone#: J Cupertino Business License #:
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 ComplZ With Cu ertino's Tear Off Policy:
Job Description: '//a
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: oc' Type of Construction: Occupancy group:
/Uoo o
Qty. if
Ap2licable 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
X17 ° s
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