04080196 CITY OF CUPERTINO .fS7a c �.
BUILDING DIVISION PERMIT gC,01vTRACTOR INFU„R'Mt1TION ,,
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT No 04080196
OW NER'S NAME: PERMIT MEE DATE
JNE: SANITARY O. C OL 440.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EIPLT PLUMB MECH
Lm usalIDCOmmed under
nderPDECLARATION Job De ALED
1 hereby affirm Nam I un 3.f
ft Bu under provisions of Chapter 9(commencing
nx with Ili ']IX«Iif Diviilonlof the Businessam Pmlfcsaiou Code,and mylicerueu
<� "n full fora and effect.
z Dana clots "if-?j Lia.« 2 REROOF W/COMP. SEP ��
Dame f-?Z- o•1 GSDECr
Y As hall
SDEC ZUU4
Y irk nJ my plan stall he used u public reenrdf 1
nad
jo� Licensed hereby affirm
BUILDING
OWNER-BUILDER DECLARATION
jclZ 1 hereby.('firm Nal 11. exempt from dnt icate. rt license Law for the
00 which following a permit ded
cDLS B.shot.imrPe(deoli CoortapiAny my stror ucture county
$ whichitsrequires;.......
.•permit to tries ilm alar,improv.,h permh u or a pair any tatement
thathe its iuuenae.ehu sequircuhe apPliant fnrsuch Pcnniuo filcasigned rammem
£a< NUMencing ad pursuant lode orDisiouof the ConwnessaLicenassw(Chapar9 Sq.Ft.Floor Area Valu non
y $ mem a r;axe pt Sectionrn add the
leads n7 of the Busalleged
inu and Proon.An lou Cndc)of
me,heu campy thertfrom and de buts for the Wcged eampuo.Any lineation of
Sect.I.. than, by any hundred
llrs x00). subjects Ne applicant .civil penalty of 35+TDI1'btEtl gr00 Occupancy Type
nay more Nm five hundmd dollars(5500). P, y '7 P
❑1.u ownu of the pmprny,m my mployee with wage as their sole compensation.
ME do the work,and me=more Is not intended or offered for sale(Sec.71144,Business
and Professions Cmc:The Conuacmra Liana Law does not apply to an owner of Required Inspections
property who builds or impraves thereon,and who dos such work himself or through his
own employee,provided Nat such improvements art not intended oroRerod for ale.If,
however,the building or improvement is aid within one year of completion,the owner.
Wilder will hass can burden of proving that Ise did act Wild or improve for purpose of
sale.).
❑1,as owner of the propeny,am exclusively contracting with licensed connecters to
construct tie project(Sec.7(744,Business and Professions Code:)The Comracrors U. .
came Law doe not apply a an owner of property who witds or improves themmn,and.
who contracts for such projects with a emmtrecmor(s)licensed moment is the CommracmM1
Lkena Law.
❑1 am exempt under Sec. ,B k P C for this Mason
Owner - Data
WORKERS COMPENSATION DECLARATION
1 hereby aRlrn under Penalty of perjury one of the following declarations:
1 have and will maintain a CaruR®te of Consent m self-insure fee Worker's Compeer
satwo,u provided for by Section 7700 of she Labor Code,far the perform.of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
7]00 of the labra Code.for the performance of the work,for which this permit is issued.
My Workers Compensation Insurance emu and Policy number ase:
Poi No
No.:- 7��fPT�a-
CERTIFICATEOFEXEMPQO&'FROMWOM K
COMPENSAr%v_rN,INSURANCE
(Thissacdon need othecompleed if ue termly is foronchundrtd dollars(S ImH
or lea)
1 certify that in the performance of the work for which this Permit Is issued,I ahall not
employ any peran in my miner a u to become subject to the Worken'Compensmjon
Laws of California,Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Escmption,you should
Wmme subject to the Worker's Compensation provisions of the Labor Cmc,you must
J z forthwith comply with such provisions;or this permit shall M deemed muted.
Z O CONSTRUCTION LENDING AGENCY
[-s work
Net then itaed(Sec.3lending agency for the Performance of
Q$ the work fur which the permit ta issued(Sec.309],Civ.CJ
L L rress
Leaders Name
L
z enders Add
U Q 1 certify that I bale mm this application and stat they the show information is
{f. correct.I agree a comply with all city and county ordinances and stale laws dialing to
0 building construction.and hereby authorise representative of this city to enter upon the,
for
V) ahave-menuuned gmerox astrty andexecuon pmpues
0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
Z flabilincoiunfumm of thecostsmdepensemiichmayinanywayaccrueagainmaaidCity
U z t.
APPLICANieUNDERSTANDS Agodding of mND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R�EGUj.ATIONS.
r1� 2 Re-roofs
S�hdum
"ApplicanUCanumtor meta
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occup til tore or handle hauummus material "
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
.dNLC.dd.Section 33333(q? All roofs shall be inspected prior to any roofing material being installed.
❑Ycs QNo
Will the applicant or mem Wilding occupant tree If a roof is installed without first obtainingan inspection,I agree to remove
pP g W equipment or devices which P g
Its icy? nu air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
0Yca MN.
�J
I have mad the hmardnusmmcrialsrtquiacments under Chapter 695 of the Glifno-
ria Health b.Safcyy CaM,Seetimr 35505.25377 arW2S57d.I understand then if the Wilding i ,P_2� -0`T
Jos nm currently how a tenant.Net it is my rtspauihilimy m notify the ocupant of Ne ry
mquiamenot which moil be met prior m issuance ora Certificate of Occupancy. S ignature of Applicant Date
y i1A� All roof coverings to be Class"B" or better
O Lir aumhorizc agent pee g
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408) 777-3228
CITY OF Fax: (408)777-3333
f[UPEkTINO
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: I GI<- r"?U/C-11 A G H
Job Site Address: / do,,' L tr/1
Roofing Company Name:—QLD
Applicant's Si6naturr: / Date:
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF g g
UPEII;TINO PERMIT APPLICATION FORM
11KPN #0,5 7�- O 0 Date:
Building Address:
/ 0511
Owner's Name: Phone#:
1CK t4 T qD� F605:1 CVL/
Contractor: Phone#: License#:
0 9c Oc I NTS r4Qo> tnlG yon- 76R5? 6 as -7� 3 /
CConiact: Phone #: Cupertino Business License #:
/ Cmc ga.- c� Co p
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles 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.
Have Read, Understand and Will Com I With Cu ertino's Tear Off Policy:
obDescription: ►2csr•�ov�s XJSTI� ��'fCn o Gink !NS ryt. 3t 1
4 t -we, 6o A— ci)M�
Residential F?5L Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are an restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
o go 3
Qty
A is "le Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCH_ K Plan Check Fee BUU DING
BUSLIC i Business License BUILDING
/7° n 6 �