04090037 CITY OF CUPERTINO s°'" - � � ' '�`� '�` • •`
BUILDING DIVISION PERMIT �,kCONTRAC°TOR I1VR,URMATI,O, --
BUILDINGADDRESS: OLD COUNTRY ROOFING PERMITNo.04090037
2985 EDLIKSTOMP
OWNER'S NAME: PERMIT LSEUE DATE
MONICA SU -
NE:
SANITARY N0'? CON7TlOL NO,
707 86 -
ARCHTTECifENGINEER: BUILDING PERMIT INFO
E MECH
0
u00 LICENSEDCONIRACIOR'SDECLARATION JobDescrip[ion
w❑ 1 bcrohy afriam that 1 am limemed undo,provisions of Chaple,9(commcneing
iW
' mfwiLiccnts
th Seetion]UIN)7 of Division3 of the Business and Prufessium Cock.antler li¢nuix y
_3dlrarte.neerrYj 9 7 REMOVE EXISTING COMP/INSTALL OCT / 204
o =
tin CI Lic.g
Dam - contmcmr 30 YR FELT/50 YR COMP
ARNue DELLA ATION
1 uMcrsuMuff nJ my plans still W axil u public rtmrds
�aU ING
u
Licensed Pmfcssionel B u I ®I
< OWNER BUILDER DECLARATION
0 Y I hcrehy.(sect the I am exempt from the Conlnclnfs License Law for the
oO which ire matin. permit ]5Dstr Business and Pmfdrima Code:Any cin at county
K which)itsissua,mast recnnss thealter.nt for such permit
or repair edswctara
m�'^
paw mitsiensedpalso
oantto ms theapplicantfor Conlarier's cense le a signed mem -
!'�< (commis licensed,unison" )of Division3 the Contoctss and cntslaw(Chap¢r9 Sq. Ft. Floor Area Valu t1 000
W (cat be Isingwith Sectinn]000)or Division3 nftWegedCssandmi.Anynnl Cnne)ur 7
i�� Net he u cscmpt therefrom Add the buts far the alleged exemption.Any violation of
Section 7031.5 by A,.,plicant far a permit subjects the Applicant o a civil penalty of APN Number Occupancy Type
not mom than five handrail dollars($500).
❑1,as owner of the property,army employers with wages as their stilt compensation, 3 6207030 . 00
willdo the wort and the structure is not intended oro@rad forage(See.7044,Business
and Profeasiou Code:The Contractors Liarve law does not apply m an owner of Required Inspections
pmpeny who builds or improves thereon,and whodoes such work himaelforthrough his a
own employers,provided that such improvemenu are not intended oroRered for We.If.
however.the Wilding or improvement is sold within one year of completion.Ne owner.
Wilder will have the Warden of proving that he did not build or improve for purpose of
sale.).
❑1.a owner of the property,am exclusively contrasting with licensed contrarian to
construct the project(Sec.7044.Business and Professions Cade:)The Contractor's Li-
cents law docs not apply to an owner of property who builds or improw a thereon.and
who contracts for such projects with a conuactar(s)licensed puuuanuo the Comncmis
License law.
❑l am exempt under See. ,B&P C fw this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
It., 1 hereby afEtm under penalty of perjury one of em following daclarrtions:
nave and will maintain a Cenificam of Consent m self-insure for WorkersCompen-
tian,u provided for by Section 3700 of the labor Code,for Om performance of Use
werk for which this permit is issued.
1 have and will maintain War Compensation Insurance,u mq.irad by Secuon
3700 of Ne later Code.for Jct perfosmaucc of Ne work for which this permit or issued.
My Workeis Compemstion l//nllsu/ran¢canner and Policy numLWr
Cartier. 41Z R/k01' Uit1g lxa iCy No.: _f C:ti-7?y
CERTIFICATE OF E%EMMON FROM WORKERS'
COMPENSATION INSURANCE
mlieuction need not W complcmd if the permit is Intone hundred dollars(5100)
or less)
1 ccnify Not in the performance of the work for which this permit is word.I shall not
employ any parson in any mentor an a to become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this CcniOcate of Exemption,you should
become subject w the Workers Compensation provisions of the labor Code,you must
.,0 faMwith comply with such provision as Nis permit 0.11 lK deemed revoked.
Z "' CONSTRUCTION LENDING AGENCY
[—r I hereby aRrm Nat them is a construction lending agency for the performance of
R' > the work for which thu permit is issued(See.3097,Civ.C.)
WWA Lender's Name
0.0Z LcndersAdd.
U O I ccnify that I have mad this application and state Nat the starve infosmavun u
"P Corea.1 agree to comply with all city and county oNinances and stem laws aching to
CU building canaroction,and hereby authonx mpacscnutives of Nis city to cnur aPnn Fac
r W alcove-mentioned property for impaction puryotsa.
(We)agree 1.save,indemnify and keep harmless the City of Cupcnino against
H h liabilities.judgments,costs and oxpcnsea which may in any way serum against said City
U in consequence of the granting of this,cam it. _
^ APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATIONS.' / � �
&tAy y(1lLJtl).?-oata� 9-41-011 Re-roofs
Sig sou of ApplicaroComrsctor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haradous material
as dclined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
DYrs Nu
Will thea applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
PP g p Area
n
t havardnus air contaminants as defined by IM Bay Arca Air Quality Management all new materials for inspection.
Wi<t?
❑Yes EKNo
I have rear)the haraNtms materials rectiremcnu sea&r Chapma 6.95 of the Cailm-
nia Health&SafctyCodc,Sccuom MM5.25533md25334.lundcn=dthatifthc building /�`/�^/!/ ✓ ! / �O /
dorsnot a hd,have a lemon Not it is my rtspomibility,b radly Ore.Cap.(of on 7
Z (whichmug W at poor anwhen ccogaccsuh<auaf ;y Signa[ eofApplicant Date
f�lR/ meter-/ 7 y y All roof coverings to be Class "B"or better
O n aushmited agent Dau
• CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36207030.00
DATE ISSUED. . . . . . . : 09/09/2004
RECEIPT #. . . . . . . . . : 26965
REFERENCE ID # . . . : 04090037
SITE ADDRESS . . . . . : 7985 FOLKSTONE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MONICA SU
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014
RECEIVED FROM . . . . : OLD COUNTRY ROOFING
CONTRACTOR . . . . . . . : FOLK, DIETER LIC # 20389
COMPANY . . . . . . . . . . : OLD COUNTRY ROOFING
ADDRESS . . . . . . . . . . : 125-B GROBRIC CT
CITY/STATE/ZIP . . . : SUISUN, CA 94585
TELEPHONE . . . . . . . . : (707) 864-5557
®E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BPERMFEE VALUATION 13, 000.00 201.96 0.00 201.96 0.00
BSEISMICRE VALUATION 13, 000.00 1.30 0.00 1.30 0.00
_______ __________ ----------
TOTAL
_TOTAL PERMIT 203.26 0.00 203.26 0.00
METHOD OF PAYMENT AMOUNT NUMBER
CHECK 203 .26 3050
TOTAL RECEIPT 203 .26
CITY OF CUPERTINO
ll— RREROOF
CITY OF
CUPEkTINO PERMIT APPLICATION FORM 6 y�o&3�
41 APN 3 6 a 0 b 3� Date:
Buildinc�Address:
4'J�
Owner's Name: Phone#:
o go�- y 4 G ��q G
Contractor: Phone#: 444D License#:
OLJCD o - nJG 1Ropt Co-;:?2 3 /
Contact: Phone#: Cupertino Business License
c #:
sss e-� r q01__ -- ka �3 0(30 5 d'9
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles, ?I;f, 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: c:` Irn 0 V L�5_ csxl S i i IJ 6 4a'f`4 0 1=
NS %c�2� d— SOyti r Gomf'
Residential K Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Constructi Occupancy group:
Qty. .
A cable Fee lD 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
Community Development Department
• Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
Fax: (408)777-3333
O U PEkTI NO
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: M 00A) I C,, 9 CSS
Job Site Address: -7q 5 rB LKS'i o Al cr -/-I ✓cf
Roofing Company Name: L ` 00V LV r00 7, G
Applicant's Signature: l; Date:
Greg teel
Building Official
Revised 1/30/03
Printed an Recycled Paper