06080068CITY OF CUPERTINO•+m.�a
CO TILa,�TUR�iI�FORMATIQ
BUIUDInamvlslon PERMIT
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BUILDING ADORES':
OLD COUNTRY ROOFING
PE"""""""06080068
22028 LINDY LN
OWNER'S NAME:
PE1tM17 ISSUE DATE
DOZIER JOHN P AND PEGGY A
125-B GROBRIC Q1
OR/09/20OG
NE:
SANITARY NO. CONTROL NO.
(707)864-5557
ARCHIlECT07NGINEER:BUILDING
PERMIT INFO
'BLDG
ELECT PLUMB MEC14
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am IlmnseA under provisions of chapter 9 (commencing
with IO)af Divltlon3a(Ue Business eM Profcwium Code,snd my license is
Licanm "99 Lk.. b�•273
nI
TEAR OFF SHAKES RESHEET ADD 50 YEAR COMP SHINGLE
LASS A
Dae Ca r
ARCH dN!
1 understand my plata l he d as public records
shall
Licensed Pmfeummal
OWNER -BUILDER DECLARATION
I hereby alarm that I am MEmpt from the Comacmh Liecnm Law for the
fallowing mason. (Section 703 1.3, Business and Professions Cade: Any city Of county
which require; a Permit m consumer, after. improve. demolish, or repair any urocture
prior an its issuance. also raparea the applicant forsuch permit to file a signed va¢ment
the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valua$W OOO
that he is licensed panuant to the provisions of
(commencing with Section 7000) MDivision 3 of the Ba rressand Prafuulans Codd or
that be u eaempt themfmm and the basis for the alleged wmptiom Any violation of
APN Number
Occupancy Type
Secdon 7031.5 by airy applicants far a permit subjects Use applicant to a civil penalty of
Ma more than Ove hundred dollen (5300).
35627007. 0 0
1, as owner of the property. a my employees with wag" as their Sale compenesdon,
Required Inspections
P
Said da Umwark, mdUte 704x.ormarof
daanertues
USE apply.
he CoelamvsI me ret apply cat owwr
and Ro Cade The Cantracmra Lures Taw
q
wort f Waugh his
property who builds aimprovrs Umrm dors uch is
who bis
r vement E in "Offfa
awn employers, provided that web improvements am not intended aoReted fa We ll,
4 Um owner
builds the building ter ore year of mpnow,
fal.r
an of pmms
s dwitid
builder will law the buNm a! proving mat he did ret Wild a impmw, fa purpose of
that
uleJ.
❑ I, as owner of the property. am "clmively contracting with licensed cmnOwmas to
construct the project (Sec. 7044. Business and Professions Code:) The Camncmr`s U.
ever law does not apply te an a mer or property who Wilds Orimpmw thamen, and
/
who castanets for such projects with a mmmucl r(O liartsed puraant to to COetrwmr`s
Oi
Liemuts Law.
❑ l nm eamhps under See , B & P C far Shu mann-
Owe Wte
WORKERS COMPENSATION DECLARATION
I hereby aRirm under penalty of perjury mm of Use following declaretons:
(�
I haw and will maintain a Certificate of Cement to self -Imam far Worker`s Compact-
talion, as provided far by section 3700 of Use Labor Code, la the perfonmes, of the
"USE for ssu
for which this mit is ied.
i bave and will maintain Worker's Compeation Insurance, u squired by Section
3 00 of W labor Coda. far due performance of the work fa which Shia permit u issued.
My Wort�/(/� Co pOemation Inwnmm ami" and Polity number as:
Caller. Policy NO.: )I % ti $ 7 -L--
CERTIFICATE OF EXEMPTION FROM WORKERS'
CERTIFICATE
COMPENSATION INSURANCE
(This se"inn wed notbecompleted if the Permit u fmranc hundred dollars ($I(D)
M, less.)
1 eenify that in She perfommaoee of the work fa which this Permit is Waned. I than na
employ anypermn In any manwrm u an become subject to the Wmlmn' Compematlon
Laws of califoreia. Dam
Applicant
NOTICE TO APPLICANT: If. after making this CaAOcate of Exemption, you should
became Subject m the Workv's Compcmation provisions of Use Labor Code you most
forthwith comply with such provisions on rob permit mail he demand! evoked.
CONSTRUCTION AGENCY
uscumnLENDING
I kr Shu mem V s agenry forme Iurmrmanm of
ed (Sm. 30 7,Wing
whichthi
� the work for which Shu permit u issued (Ser. 7097. Civ. C.)
'
Lender`s Namc
Under'Add.
iI easily dust I have read Shu application end sum Shu dw above inronnsdun W
' correct. I agree to comply with all city and county oNinsmm and sum laws relating to
building contraction, and hereby autharim mpresenutivet of oris City to cner ulmn the
above-mentioned property for inspection purposes.
(WE) agree to Save, indemmfy and keep harmless the City of Cupertino against
liabilites.ludgmenu,cosu and expenses which may in any way acerae against aid City
ire consgww ( tie gnntrng of permit.
' APPLICA NQE0.5;pIN AND WIL OMPLY WITH ALL NONPOINT
SOV�77�g5. /
Issued by: Date
Re -roofs
Type of Roof
Signs= or ApplicantlContrwtor OEM
HAZARDOUS MATERIALS DISCLOSURE
Will the applianta future building occupwtms ahandle hr"adom material
as detned by Ue Cupertino Municipal Cade, Chapmr 9.12, and the Health and Wcty
Code. seen.. 25532(4)?
All roofs shall be inspected prior to any roofing material being installed.
❑ YOU
If a roof is installed without first obtaining an inspection, I agree IO remove
Will the applicant or future bending Occupant use equipment a devices which
emit hWardom if contsmim arts as de0ned by me Bay Amo Air Quality Management
all new materials for inspection.
District?
❑Yea
Ihaw Mail the h.S.a muerlW5533 w5534.1rChePler
undersande
OuirheCalding
nus"IShkeafuyhawAsavamhat
+3• 9 Q �p
ItU2MYresp125534.I
cu Ifihe
da" Inst currently how a enm4 Net It u MY responsibility m noUl'y the repent of me
require a hicharstbee� L 'naiuu araCeNfeawar
Signature of Applicant Date
9106
All roof coverings to be Class "B" or better
Pv
Gybe cyemy
om 3 of 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35627007.00
DATE ISSUED.......: 08/09/2006
RECEIPT #.........: 35572
REFERENCE ID # ...: 06080068
SITE ADDRESS .....: 22028 LINDY LN
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: amyw
COPY # : 2
OWNER ............: DOZIER JOHN P AND PEGGY A
ADDRESS ..........:
CITY/STATE/ZIP ...: ,
RECEIVED FROM ....: BONITA JENKINS
CONTRACTOR .......: FOLK, DIETER LIC # 20389
COMPANY ..........: OLD COUNTRY ROOFING
ADDRESS ..........: 125-B GROBRIC CT
CITY/STATE/ZIP ...: SUISUN, CA 94585
TELEPHONE ........: (707)864-5557
•FEE ID UNIT QUANTITY
---------- ------------- ----------
BPERMFEE VALUATION 13,000.00
BSEISMICRE VALUATION 13,000.00
TOTAL PERMIT :
METHOD OF PAYMENT
-----------------
OTHER
TOTAL RECEIPT
•
AMOUNT
------583.29
583.29
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
201.96
----------
0.00
----------
201.96
----------
0.00
1.30
0.00
1.30
0.00
----------
203.26
----------
0.00
----------
203.26
----------
0.00
NUMBER
------------------
MASTERCARD
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
• Telephone: (408) 777-3228
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
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:
Job Site Address:
Roofing Company Name: O!�
Applicant's Signature: Date:
• Greg Casteel
Building Official
Revised 11/2/04
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:
Job Site Address:
Roofing Company Name: O!�
Applicant's Signature: Date:
• Greg Casteel
Building Official
Revised 11/2/04
air
�UPEkTINO
9
JOB ADDRESS:
22va8
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telepbone (408) 777-3228
Fax (408) 777-3333
Building Department
/ ' 9 / _ I PERMIT #
OWNER'S NAME: gqg I PHONE # 2'6 S—/7 L4y
GENERAL CONTRACTOW r7 /d t�.�... _ f/. I FAX #
I am not using any subcontractors:01d C&, r(5 .�
tgnature Date
Please check applicable subcontractors and complete the following information:
60
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
• Gid C& T&a -
O er ontractor Signature
64a G
Date
•
0
US
CUPERTINO
o c�o800c�3
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN # 3 5 L 2 1 D O -1
Bldg Permit Fees
Date: 9/0 6
Building Address:
Energy
2-2-0 2 $
I BSEISMICRE
Owner's Name: n ^
fV-t-c.`J
BUILDING
Phone #: �6 5 � � 7 � 4
Contractorb
BUILDING
License #: 6 2- Z? 3
Contact: W VCupertino
BUILDING
Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
❑ Asphalt Shingles
)! Asphalt Shingles
';t Wood Shakes
❑ Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings >
❑ Provide I.C.B.O. Report #
"0I To be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Co%ply With Cu
ertino's Tear Off Policy:
Job Desca'R n:
J oti
a G1GP 1Q G,
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planning D10t. if
there are any restrictions: LJ
Cost of Project: oz� Type of Construction: Occupancy group:
13, DD
Qty. if
Annlicahle
Fee ID
Fee Descrintion
Fee Grout)
BPERMFEE
Bldg Permit Fees
BUILDING
BENERGY
Energy
BUILDING
I BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING