03010103 CITY OF CUPERTINO - - e
r 6UILDING DIVISION PTRMIT CONTRACTOR INFORMATION
Eu[LDINGADDRESS: GROMO ROOFING~ PERM]INO.
20087 PACIFICA DR 03010103
OWNER'S NAME 121 W WASHINGTON AVE APPLICATION SUB DATE
SIBLEY NANCY M TRUSTEE 01/17/2003
IONE (408) 746-2075 SANITARY NO. CONTROL NO,
ARCHITELTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTORS D ON
1 hereby allirm That I am liccnud under pmvisiomisinns off CCboPmr n(commencings Job Description
with Section and of Division3of Ne Busines�nd Prnfexvions Cnde,and mylicense is
� N in full force unJe t. IlJ��J� REROOF
zogz License Cluav f 7 Lic.x
oz—'ooa� � r' caner T/0 SHAKE, INSTALL 1/211 OSB & 30YR COMP . SHINGL
F=t—N �pkCDCFF,l'g0 LARA
F� 1 understand my plans shall he used as public moor
NAL ED
w0 Licensed Prol u.inual
1 OWNEnt exempt
DECLARATION
u�02 1 hereby u(Sect than 1 1. exempt from the Cuntrannr'.Q.rgc{¢1 ullfa O']
ad GO billwhich
(Section 703 1.5. deibli Coe: n1 u J
$ which requires manner,permit re ammrthe aper,improve,demolish,or repair any structure
prior ata thathe itsensedppotential
oalto theres provisions o for such Contromtiun file aligned statement
1"ze nhmhciningwithSectio 7(XXEerovisinnxoftheCommnadsl. I Sq. Ft. Floor Area Valuation
tea'tWis xempttheefromand[beIdiiafrnnheeeme,aanSl I $6980
Thal he is exempt therefrom and Bm basis for the alleged exemption.Any violation of
Section 731.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more than five hundred coolant($100). 36929003 . 00 p y YP
0 I,as owner of Ne pmpeny,or my employees with wages as their sole compensation.
will du the winds,and the strucwm is not intended or offered for sale(Sec.]BOA,Business
and Professions Code:The Contractors License Law docs not apply to an owner of 305 - FRAME Required Inspections
property who hot Ids or improves thercnn,and who dues such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If, 307 — INSULA'T'ION
however,the building or improvement is sold within one year or completion,me
601 - ROOF TEAR OFF
sale.). 602 - ROOF PLYWOOD NAIL
E]1.as owner of the prapeny am exclusively contacting with licensed commumra 10 603 ROOF BATTENS
convect the project(Sec.7Wq Business and Professions Code:)The Conlraanre Li
cense Law down,,,apply men ownerof jimpeny who builds,,,improves thetcnn.end 604 - ROOF IN-PROGRESS
who contracts for such projects with a c,,mmctor(s)licensed pursuant to the Cnmrecom s
License Law.
❑1 the exempt under,Seo. ,B&P C fit,this reason
Owner new
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declamniens:
I have and will maintain a Ce difcam of Canaem to self-insure for Worker's Camper.
sation,as provided for by Section 3710 of the lshor Cade,for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37X1 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation lnsur nw eurtier and licy number am:
rtier /rT :rte Fv/a�/7 Poli t,FI- ��SJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This union need not he cnntpleted iRhe lnrmit is for one hunched dollars($100)
to,Icss.)
I unify thal in the performance of the work for which this ormol is issued.I shall not
employ any person in any manner in as to become subject to the Workers'Compensatinn
Laws of California.Doc
Applicant
NOTICE TO APPLICANT:If,after making this Cenilimte of Exemption,you should
become subject us the Workers Comm:nsition pmvisinns of the Lahr Cade,you must
OO forthwith comply with such provisions nnhis perm shat l be deemed rewked.
z CONSTRUCTION LENDING AGI7NCY
[-+(Zt I hcrchy allirm that there is a commruction lending agency ter the performance of
�i > the work for which this permit is issued(See.3091,Civ.C.)
tQ Q Lender's Name
G Lender's Address
� z
V P 1 certify that I have read thirty and coup and state that the show information g is
0 F building I agreeonstr In comply with all city and representatives
ordinances and sum laws relating to
V above
gcunaned ,o,undhcrebyameoriw rcprcumativcs of this city menta upon the
r I2I uhove mentioned to saifyve fur emnify an keep es.
Pile)sju agmen In cavi,indemnify and keep harmless the City of Cogent against
Uco)Z infoises.jurreoft egrasing of this expenses which may in any way aroma against said City
1.1 z in
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATI NS.
Re-roofs
,amettre m ApplicanUConv.,. Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applmom or future building oMcupam sore or handle ha ardour mamrial
az defned by the Cancra,Municipal Cuda,Chapter 9.12,end the Health and Safely
axle.Sen es 2353x')7 All roofs shall be inspected prior to any roofing material being installed.
❑rex laths
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
mil Invadous air contaminants as dcftned by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes t5IN.
1 have mad the hm,ardnus materials requirements under Ciupmrfi 95 of the Cull For.
nits Ilealth&Safety Codd,Secuem25505,25533 and 25534.1 undersand that if the huildirg /s
dons not currently hove o I at,thin it is my responsibility to motif y tbe nccupam of the ._^ /lex O�
tequircmenul which mel pnonnissuancc ofa Ccrdfca of Occup�c/ i gnatu re of A p p l i cant Date
or or ephorizzat agent /��• Dam All roof coverings to be Class"B" or better
Building Division
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: (408)777-3228
Cl Fax: (408)777-3333
CUPEkTINO
Building Department
Subject: Reroofing policy for the City of Cupertino.
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufactures specifications on reroofing.
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 reroofing 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) Preinspection 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 that the
proper City inspection can be performed.
IMPORTANT:
1. Flat roofs must have a minimum of V"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 of inspection.
We understand the above policy on reroofing and will comply with this policy.
Homeowners Name: - 2s'_ ?ii�it. C y s,/ fix
Address: 2P01-' 7 f yciFle'-�;' D,c - rVl,'4- t 7 iso
Reroofing Company Name: G��' d (7 00 Li.✓ G�
Applicants Signature: �— " Date: / a
Joe Anionucci
(Chief Building Official)
6/25/01