04080058 CI'CY OF CUPERTINO '? - �
BUILDING DIVISION PERMIT CONTRACTOR;INFORMATION �-I
BUILDING ADDRESS: PERMIT NO.
OLD COUNTRY ROOFING 04080058
OWNER'S NAME: PERMIT ISSUE DATE
ONE.
SANITARY 0. ROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
app LICENSEDCONrandunOR'SOECLARATION - ���®
til❑❑ I hereby arLIC the 1 am Record under provisions ATION¢r 9(cnmmennng Job Descripti
iW with Secti T BofOivision Softhc Busin�rofcuinm dgandmylimenseie
jai lianm ersaderrat„ .? uc.x �a {n�j/ REROOF W/COMP. .
.w Dam Co.,..,EC5EPA/ 2004
11
ARCHITECTS Co. A
wys 1 tl&"and my plans shall he used as public records
JyU
3 G Licensed Professional {l II t�j
i g OWNER-BUILDER DECLARATION py071%I tlLy�l'7gl^S/1J1 e
<Y I hereby al'fnn
that I am exempt from the Contran0rs License Law far the
_
00 following age an.(Section 703 IS.Basin.and PlO(essioos Cade:Any city fir county
x'm which mquims a permit to Confwct.eller,improve,demolish,or repair any awerure
prior In its issuance.also mquires the applicant for such permit to B le a signed statement
t?'<
that he is licensed pursuant to the provisions of me Contractor's License Law Chapter Sq. FL Floor Area Valuation
re'o (commencing with Section?(100)of Division J of the Business and Professions Code)or
i Out he is exempt thcreftom and On huts far On ailcgcd exemption.Any violation or
Section 7051.5 by any applicant for a permit subjects the applicant oacivil penally of 32VN'X*8)gr00 Occupancy Type
oat mart man five hundred dollars($500).
0 1,as Owner of the property,or my employees with wages as heir gale co epansation,
will do the work,and thesvuctom is not nlcnded or offered for sale(Sec.)044,Business Required Inspections
and Profusions Code:The Conmemes r's License law donot apply to in Owner of q p
Property who builds or improves thereon,and who doessuch work himself or through his
own employees.provided Oat such improvements arc not intended or offered for sale.If,
however,the building or improvement is Sold within arc tear of eompmhon,On Dwncr-
builder will have the burden of proving that he did not Wild or improv,for purpose or
Sale).
0 1.as owner of On propsny,am exclusively contracting with licensed eonmeures to ,
Construct the pmjecl(Sec.9044.Business and Prorraions Cade:)The Contractor's Li.
me Law dna not apply to an owner of property who Wilds or improves thereon,site.
who contracts for such projects with a eanmctor(s)licensed pursuant to the COatrtmon S
License law.
0 I am exempt under Sec. ,B k P C for this reason
Owner i Date
WORKER'S COMPENSATION DECLARATION
41 1 hereby affirm under penally of perjury Ore of the following declarations:
1 have and will moinuin a Cerdfieda of Coosent to selbing re for Worker's Campers-
ution,as provided for by Section 37M of the labor Code.for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation insurance,as required by Section
)Ap of the labor Code,for the performance of me work for which mis permit is issued.
My Worker' Cn ns firm lnsurantt curler and Policy ml W r)am:
Cartier. ,GI r Polity No.:��f W a� 1
J_-)
CERTIFICATE OF EXEMPTION'PROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if the permit is forouc hundred dollars GI00h
less)
1 certify that in the perturmanec of due work for which this permit is issued.1 shall nm
employ any person in any manner an u to became subject to she WDrkera'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:Ir•after making this Cenificae of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Chun.you mug
.�Z rordwith comply with such provisions or this penditshall be deemed mvid ed.
zO CONSTRUCTION LENDING AGENCY
PI hereby affirm that lht.is a mrngmcainn ltbrift:gem,for the perfurmane of
C the work for which this permit is issued(Sec.3097.Civ.C.)
Lendces Name
0.
= z Leromes Address
U Q 1 eerily that 1 have read this application and sum that the above information is
c. PCromer.1 agree to comply with all city and county oNinancn ante laws anlaws relaing to
I]U building construction.and hereby Sigorina repmxnuthes Olrhis cry to enter upon the
W above mentioned pmperty for inspection purposes
(We)agmn m save,inden tfy and keep harmless the City of Cupenino against
liabilities,judgments.Cosa and expenses which may in any way accede against Said City
U in consequence of the granting Of this permit.
'—' APPLICA , UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR E GULATIONS. / c
i rLtJ H.,r /%aJc,,p.✓ C-04 Re-roofs
Sig un bf ApplicanVConuacmf Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupantstore or handle hazardous material
as dcrined by the Cupertino Municipal Code,Chapter 9.12.and me Health and Safety
Cade.Section 25532(a)?
Year
NoAll roofs shall be inspected prior to any roofing material being installed.
Will the applicator or future building occipam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havardnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0Yes No
1 have mad On h-.t materialsroquimmcnts uO&,Chapter 6.95.(the CdIlIOf-
riaHcalthkSafctyCrde.Sccuwu25N)5.i555BandM53 .1undcrsundthwirthm Wilding �,' ,(r a,
does rot filly have a tenant that it 4 my r,sprraihility to notify the oncow,rf the �Wc^-�G !ovV✓(/'-Lit%)� si ( 4 /
Input n(s whicM1 mussW spit`;w issuanc,bficcnifica�pyrf upanoy. t —se
pd.,
-/kms) O-�J-(� ignatureofApplicant Date
o n aamari..ca:pent Dam All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
! � Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building De artment
JOB AD E S: PERMIT #
OWNER'S NAMIJ., VIWZt. ke.WA PHONE # t• 35.3-loMO
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature 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 ( >->qv
Septic Tank
Sheet Metal
Sheet Rock
Tile
—0
e /Contractor Signature Date
' Community Development Department
Building Division
C4 I City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF�
UPEkTINO 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: l-< 4-L—
job Site Address: --' U(0 X:r,^t 0 r<D
Roofing Company Name:
Aphcant's Signature I tULr/^ Date: G J y
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
'RFAPN # OQ Go cq6 Date:
Building Address:
'oda aS CU c%r?TINp l�
Owner's Name: ones�
9 0 .. 3iDa/ 0
Contractor: Phone #: License #:
0 L��, ) C.o (4 A/-T-,Q oar- /✓( VO(P (F3 L o
Contact: Phone #: Cupertino Business License #:
1/0 �_
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof `❑� Built-Up roof
C3 Asphalt Shingles >< Asphalt Shingles
A Wood Shakes C3 Wood Shakes
❑ Wood Shingles El Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
lob Description: r�,,Em vVcs LF'/ i 5--t/od rz-Y W o o�
<3 0 1--r -- L-t Qs
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with PlanningOD,_ept. if
there,are,any restncuons. �
Cost of Project: Type of Construction: Occupancy g up: 1
Qty. .
Appqcap1 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 i Business License BUILDING