04040152 CITY OF CUPERTINO
nuu.Dtnc DIVISION PERMIT aCON':TI2AC7OR INFORMATION:-
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BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT N004040152
10409 JUDY AVE
OWNER'S NAME: PERMIT ISSUE DATE
FARI RUCSAK 125-9 GROBR C 04/23/2004
ONE: SANITARY NO. CONTROL NO.
(707) 864-5557
ARCHITECTIENGINCER: BUILDING PERMIT INFO
BLDG CLF.CT PLUMB MECH
0 0 0 0
moo LICENSED CONTRACT OR'S DECLARATION
I hcmby affirm Thai 1 am licensed under Provisions of Chapter 9(commencing Job Descrl th�O`n+I'm`\1p1//[]��
_ ' with Station)(XXB of D iviMrso 3 of Ne Busineav and Pmfcesian,Code,and my license is 9 MY 1�a(Y`1LE®
in full force and effect. REROOF
,g>
License Class Lie.. MM 20 2004
Dare Lot.
ARCHITECT'S DECLARATION
2 U 1 understand my plans shall he used as p.him rcemdx
ia� Licensed Professional
cog OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from me Contractor's License Law for the
p o following reason.(Section 7031.5.Business and Pndexxinns Code:Any city or county
which aq.ir it Permit to ennsvuu.alter,improve,demi or repair any trmmum
ni„ prior to its issuance,also requires the applicant for such Permit o file a signed statement
< mat he is licensed pursuant the pmvorms or the Contractors License l.,w(chapmt9 Sq.Ft. Floor Area Valuation
yrs (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y Nat he is exempt Nertfrom and-the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a plaint subjects the applicant to a civil Penalty of 3-A`P&aq(bFAcr00 Occupancy Type
not more Nan Gm hundred dollars($500). _
❑I.as owner ofthe bripen,or no,employees with wages as their all Compensation.
will do me work,and the structure is not intended brbffered for sale(Sec.7044.Business Required Inspections
and Professions Code:The CommonC ns's License Law docs not apply to an owner of q p
propcny who builds or improves thereon.and who doessuch work himself br through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,me building or improv rrum is sold within one year of completion.the owner.
builder will have the burden of praying that he did not wild or improve for purpose of
sal.).
Cj I,as owner of the property,am exclusively contracting with licensed contractors to
oawct the project(Sec.7044,Business and publications Cade:)The Contractors Li
cense law docs not apply to an owner of prnpcoy who Wilds or improves Belmar,and
who almost.lar ouch projects with a eonuactor(s)licensed pursuant to me Contractor's
License To
0 I am exempt under Sec. .B 6 P C(af this rcaon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of rw following declantim s:
7sation,
haw and will maintain a Cenifcam of Conant to self-ins.¢for Worker's Calico
as provided for by Section 3700 of me Labor Code.fm me performance or the
k for which this permit is issued.
have and will maintain Worker's Compensation Insurance,a required by Section
1 of the Labor Code,for the performance of me work for which itis permit is issuedWorker's Compensation Insurance/t�arsier and Policy number am:
er:NRT G 11U16.)Allele lily No.: AjC— 6Sf912
CERTIFICATE OF EKEMITION FROM WORKERS'
COMPENSATION INSURANCE
(This seaitm need not W completed if rW Permit is for ore hundred dollars(5100)
or less.)
1 certify mat in the perfrm,arce of the work for which this Permit is issued.I shall not
employ any person in any manner sit as to become subject to r W Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making his Ccnifcate of E.cmption,you should
become Subject m the Worker's Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this ptrmil.hall W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
1-.N.. I hereby affirm hat mere is a construction lending agency far me pertturromm,of
7 the work fur which this permit is armed(Set,3y7.Civ.CJ
W Q Le rate's Name
z Leaders Address
V O 1 certify that I have read this application and state met she above information is
W f" correct.1 agree to comply with all city and county ordinances and Stam laws relating to
�U building construction,and hereby mimane representatives of this city to enter upon the
W abovetms,judgmonedents,
proPc costs
for impaction purposes.
FW (We)agree to save,indemnify and keep harmless me City of Cupertino against0.
rA liabilities,judgments,cos.and expenses which may in any way eccrvc against said City 2
U inconsequence a granting of Bar permit. TH
EALL Dale
SOURCE
O
^' AN U ERS DWI�. L/ TH— Issued by:
SOURCE 'G ATIONS. -
L Re-roofs
Signator Appfcant/Contractor Iare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant us future building Occupant store or handle hanNuus material
as armed by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
dc.Section 25532(.)1 All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
rat h...rdous air mitarnments as defined by the Bay Area Air Quel'ny Management all new materials for inspection.
ricR
❑Yes
IhamaaJmehma rwematerialsmquimmcn.un@rChapter6.95ofthcCalifor- /�
niaklcnIO&S cry Codc,Sccium25505.2 33 a�Id25534.1mccrsundmmifthtWilling — % 23
141
does net ray how.an. .wt Its 0,w notify the meup of me
require n which must cnifamnf0.cupacy Sigli ureofApplicant Date
r or umot agaat o All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
✓ Cupertino CA 95014
xATelepbone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building Department
JOB A KESS: PERMIT
/0y09_ , ✓ . sL
N
OWNER'S G
PHONE -
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 L 2 G ?
Septic Tank
Sheet Metal
Sheet Rock
Am Tile _
X-15',,erl Contractor Signature ✓ Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY Of Fax: (408)777-3333
IUPEkTINO
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: FezI :1
Job Site Address: O c/C 9 '::r(A u ✓tL
Roofing Company Name: 0L--iPp�L�7U n1'! -_4 fKOOFi-G
A plicant's Signature:_r !�✓��� Date:
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
aNe /6 Yc)9 .T V
CITY OF CUPERTINO / od 7_1150-1
REROOF �NAK(� T V4ss o L r
C F
CITY OF
PERMIT APPLICATION ORM ajff 6SO 32Z�o$o x461
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APN# r— ( Date:
Buildi ddress: P_ or� /Q-r
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Owner's Name: Phone#:
r-PX1 /OF
Contractor: Phone#: License#:
OL_. L®N nr r- G L/ OP F-000 G as 3
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
X Asphalt Shingles X 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 Com 1 With Cu ertino's Tear Off Polic :
Job Description: ►2 C-m O V A c�X l ST i o rz co_ ei
Inks nr�t-t_ 3(0 ttrz�� -+— C —,/q,,-V
Residential 9 Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: L1
Cost of Project: Type of Construction: Occupancy group:
� G o�0 l'Zc�✓-Zoe r— �
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
-2-
7, 6'