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05100181 CITY OF CUPERTINOHaag, +x) � > BUILDING DIVISION PERMIT N'tON�TRACTOWINFOUMATION BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT NO.05100181 ER's NAME:. FERMfr ISSUE DATE JOSEPH CLARK 125-B GROBRIC CT 10/9,1 /2005 PHONE: SANITARY NO. CONTROL NO, 707) 864-5557 ARCHITECDENOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH e +IOQ LICENSED CONTRACTOR'S DECLARATION Job Description U 1 hereby affirm am Met 1 limned under provismos of Chapwr 9(commencing with Section 7M)of Division 7of the Business and Professions Code.and my license is a Imfsllforceande L3 G ZZ73.J T/O ROOF RESHHET USB/ADD 40YR COMP SHINGLE pp Z_ Lkcve$1 a Lk.g _ F Dm /�L ontracmr ?q ARCH SD 22 I understand my ph He ;6 y esti Licensed Professional .�y OWNER-exempt RDECWRATION 0i Ihereby.(fcmon 1 a.1. exempt Imre the Canlns;Co n:Antt Law for Me 0 o following aorta.(Section 7 oratr Business and improve. de ons Cade:Any city or county $ whish requires a pmmb re enmtrm4 pWr,impmw,h Moral or alt ti mash nY atrunan $8500 pnormiucensed issuance. Me the applicant of eswhpctors Lfcuse,re a gaed w(Cha mem < (ffiat he comate cngwithSewantt00ttprovivionso of Me0ha meraluensesAonsCodlom9 Sq.Ft.Floor Area Valuation ��o that cad id Section,and ndthe iaiiiofrth al Bed axe andProfessionsCoda)or that o us enmpt may applicant li nal the bub for We alleged exemption.Any Wolman of Section IDl h3 by any applicant for•permit subjects the applicant to•civil penalty ofr Occupancy Type tont mom Nn five hundred dollars($500} 1,is owner of the Property,or my employees with wages u Weir nk compimmu on, will do the work,and Waavucmre isnot intended or offend fmule,(See.7044.Business and mywh build, Code:The vesCoromandele e,License Law does not apply if an owner is Req n��® propnywho Wilds orireprowathereon,sedwho doesouch work confirmed his ownem.Me Wilding prouchimproid within not year ofdmanered ror soler. bultdor,We Wilding ar improvement is old within one Yema impletion,the use of ' Wilder will Wve the burden of proving that W did n"Wild m improve for purpose of /�,A sett.)' P4Y y ❑1.u owner of We property,am exclusively communing with licensed contractors le ZU�6 construct the protect(Secapply 1.so comer eof and Professions Wild, Cade)The Contractors rt BUILDING meseLaw dmrnouch plro teaswith ofproperty)who seddsorimpnws Wenon,nd, U p��� who rontncufor such projects withacontracmrb)licensed pursuant todse Contranots .rr/' Lkense l-aw. ' ❑1 am exempt under Sec. .B At P C for this mann net Date WORKER'S COMPENSATION—DECLARATION I hereby silicon under penalty of perjury one of the following dedammiou: ❑I have and will maintain a CenlOalo of Consent in self-insum for Wodm`&Compen- noon,u provided for by Section 3700 of the Labra Code,for the performance of the work for which this permit is ivued. 1 have and will maintain Worker's Compensation Insurance,u required by Section W of the Lmor Code,for the perfmmnce of the work for which Wb permit is issued. My W� �0`'Ppe tan ms easier sed Polity..MW Carrie �J Ilcy CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (Imus section need not W completed ifft permit is fmrane hundred dollars(SIp) or kis.) 1 cenify that in the performance of We work for which this permit is issued,l shall not employ anypernn in my mnnern u in become subject to be Workers''Compcmnion Laws of California.Data Applicant NOTICE TO APPLICANT If,after making this Cenifiase or Exemption,you should become subject to the Worker's Comrcmetion previsions of me Lather Code.you mum .J O forthwith amply with such provisions or this permit Nall W deemed reveled. ? CONSTRUCTION LENDING AGENCY [••• I hereby affirm that Wen is construction lending agency for the Performance of We work for which thus pemd,is bused(Scc.3097,Civ.C.) ' 0.Wi Q Lender's Name .7 z Lenders Addnu V Q 1 mnify that 1 haw read this application aM sum that the show Information is p. corecL I agree to comply with all city and county ordinances and state laws misting M 0 building commuction.and Wrathy militarismmpeannuuins of this city to color upon Ott W ahove-romfioned Property for inspection purposes. gy (We)agree to caw,indemnify sed keep harmkss the City of Cupertino against S44 ,.y y liabilities,judgmens,toss and expenses which may In my my am=against mid City U'z ,near of gnu on of this L APPLICANT U RSTAN ILL CO Y WIPH A %��NT Issued by: . Date �2� pt SOURC O Re-roofs A/Lal._ Signature ol'Appliam/Comnnm DAM HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupntamre"handle huarcous material as defined by the Cupolas Municipal Code.Craft 9.17.and the Health W Safety de.Section 2.5577(a)i All roofs shall be inspected prior to any roofing material being installed. ❑Yu �� ones the applicant or toren building occupant use equipment or devices which .If a roof is installed without first obtaining an inspection,I agree to remove emit havardaus air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection. Dinkt7 ❑Yea M6 Its avanatlthe huaMnm 25505.25533remcnu34.lun uplord.93of WildinS ror- seta.not Code.Saart, 23703,24377 atld75371.1 undersand that,the Wilding dace nm curmndy how a lonanL that B is m mapomlhility m nodl'y the mcupnt of the ngainemenu whk IWmetp' rtos mane incase ar aapat�/ Signature of Applicant Date y/as Owner orae orindagem Date roof coverings to be Class"B"or better CITY OF CUPERTINO I• 3 of 3 PERMIT RECEIPT OPERATOR: suem COPY # 3 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34216071.00 DATE ISSUED. . . . . . . : 10/21/2005 RECEIPT #. . . . . . . . . : 31692 REFERENCE ID # . . . : 05100181 SITE ADDRESS . . . . . : 10555 S FOOTHILL BLVD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JOSEPH CLARK ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . CA RECEIVED FROM . . . . : BOBBI J PEMBERTON CONTRACTOR . . . . . . . : FOLK, DIETER LIC # 20389 COMPANY . . . . . . . . . . : OLD COUNTRY ROOFING ADDRESS . . . . . . . . . . : 125-B GROBRIC CT CITY/STATE/ZIP . . . : SUISUN, CA 94585 is TELEPHONE . . . . . . . . : (707) 864-5557 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 9,000.00 158.76 0.00 158.76 0.00 BSEISMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00' ---------- ---------- ---------- ---------- TOTAL PERMIT 159.66 0.00 159.66 0.00 METHOD OF PAYMENT AMOUNT NUMBER - ----------------- ------------ ------------------ OTHER 327.70 VISA TOTAL RECEIPT 327.70 • OCT-21-2005 08:43 OLD COUNTRY ROOFING 4087828301 P.01i01 Cemmuairy Development ,y 1030D Torre Meow ^ I Clrpccvne Gl 95014 TelephoA,(406)777-3221 CITY Of Far.(408)777.3333 CAPER`Iran <s�1��3��18 z. - Z�uM1, _ Buildin Ike axtment JOB A UPESS: _ I rt>vm #O 57)00 $1 IQ_��� S• ��i"' C)WI�F '9I�IA?vtL: � S t� /° [.,/��PI•IUI`�E # O �v <.t' GF'TvEP�L CQI:''IR_�CTi7P: OG:, �ij(•,( � i F,AX # O� '�8'� '3 O / �' 1 a,t� not using any subccnrractors�•� _ ©- / '� Signzlvre Date I,!..ea:;p ,i I;:c k. ::0pucah.lC 11 h(:4n17actOrs aTi ej cornp!ete the fDljm/ n Tg n irdo aben! —i - UtiCUi�T:—.. .--_..._— — _ . LICENSE 0 Rt1.C'T(-`,R DLISTNL55 *:i' IE BUSINESS _7 Cabincis Fr Millwork r Cement Finislung -- L`iechical i i=Ycavalion .. i _.._.•. ---I Fencing �— ---IEoorin�,: Carpedng _ f_i;nolrurn / Wood • � — � Gla-s / Cilazu�;;_.—_ __.. ...___. _ HeaHng �— lnsulatian I ^I Landscaping -- 1_.�Lh.in� I — ', r_icu'r�entai5he�tNfetal i �- `. _._...._._.__._ T'lastering �T - rPlumbing Sq,tir T`LtR S)w1'.t.Nli�tlU -- �_-- Sbcct Rock^ _— — • 0hvnar Contractor Siplature Date TOTAL P.01 CITY OF CUPERTINO REROOF OCUPEIZTINO PERMIT APPLICATION FORM APN# / Date: /2�l 0 S Building Address: Owner's Nam . Phone#: �a � ) ZS - 2 0 Contractor: Phone #i License#: D(CP 40r? 2 2 _,5-300 Contact: Phone#: S � Cupertino Business License#: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof 1 Asphalt Shingles -. Asphalt Shingles Wood Shakes ❑ Wood Shakes )14.. Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) �N rnber of existing coverings ❑ Provide I.C.B.O.Report# p To be Removed ❑ Provide Mfgr.Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Polic : Job Description: T/o C9) /Lo..o4C..LvP v 5 . 0.d4 510 e� L Residential ❑ .. Commercial ❑ _ Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if there are anrestrictions: IJ Cost of Project: Type of Construction: Occupancy group: Sao • i5b 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 Community Development Department Building Division City of Cupertino • 10300 Torre Avenue OCITYOF Telephone: (408)777-3228 C U P E��'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. Homeowner's Name: `� u a�—R lXr.� ►� n lob Site Address: 5n Roofing Company Name: O l (gym Applicant's Signature: Date: ),0/-2-//0-S • Greg Casteel Building Official Revised 11/2/04 Printed on Recycled Paper