05110044 CITY OF CUPERTINO BUILDING DIVISION PERMIT - pCON2,RACT(7RRIPPPPPPORMATION
BUILDING ADDRESS: OLD COUNTRY ROOFING 'ERMITNo'05110044
10631 SANTA LUCIA RD
OWNER'S NAME: FE UsTr ISSUE DATE
KIM ADAMS 125-B GROBRIC CT 11/08/2005
NE:
SANITARY N0, CONTROL NO.
(707) 864-5557
ARCHITECr/ENGINEER: BUILDING PERMITINFO
BLDG EIPCT PLUMB MECH
I� E (�
+Oo LICENSED CONTRACTOR'S DECLARATION
im❑ 1 hemby affirm mm 1 am licensed under proviau"of Chapter 9(commencing Job Description
iW with Section 7")of Division 7 of the Bud. aM Profcsi w 4 and mylic seis jrm
+« mranmaeand�ec� REROOF-T/O COMP /_I�DV ZP. SHINGLES
license
iD,te onuactw lJ
ARCHITECTS DECLARA � N
46-0ED
or u u reJ
1 understand my plans shall be used public cords Q
LL
professionalLA
Licensed professional
OOWNER-BUILDER DECRATION
1f�'try �QQ(aa
x I hereby aRrm the,1 ear exempt from the Camisole.License Law far dm U
a O following reason.(Section 1103 1.3,Busirss and Professions Cade:My city or county
<$�i which mquims a permit m construct,ales.improve.demmtah,or repair any structure BON J/pJ'1f p ij{ $8000
Y2Y prtarue iLii3alWlee,,Ie ulmsmeapplicantfocsehpcsmi,w Bkasiglmdslalemcnt
< mmhekl weaparsa. lmBtepm.i ons orutecnnaa oraL�nro�w(c„apk 9 Sq.Ft. Floor Area �(�l t l Valuation
x.$x \/
Outhic .wounpth Su4iw 70nd the
basis
Ofineged incoaption. yvi1.6an of
Out he u exempt mmc(rom and me lases fm the alleged emmpuw.My violation of
Section 70315 by arty applicant for,permit subjects Ne applicant b a civil perealty of
wt more Nan five hundred dollars(35007. r Occupancy Type
❑I.uower of Ne prolmrty.ormy employer wire wagwulheLsok compewtion,
will dOthewods,ande: he Cm ton's License .it fo.1apply 7066,Bnel of Required Inspections
and property
whoW Cade:The v eJuscar's License Law dors ret apply lo an owner of fl P
me eny who builds or ire prow chicon,and who awn such wrote Mmul f offered
his
Owe employees,provided Item such improvements are not ear of
aroaemd roe mover.
bowev.Ne building o,improproving
is sola within one year or completion.the ower.
builder MB have Ile bu,den of proving that he did ret build or Improve for purpose of
ukJ,
❑1,u Owner of the property,am exclusively contracting with licensed conlracbn k
co earma the project(Sec.7064,Business aM Professions Code:)The Commissars V-
cense Law does not apply 0 an Owner of property-who builds Or improv thereon,and
who compacts fns such projects with a conuam er(s)dossed porus.,to the Contractor
Licamin Law.
` ❑IamuunptuMer See. ,BdvPcrwthis.
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declamation
I h,w am will munuin•cutiftc,m orComem to self-iwum for Wmke's Co.,.-
sarion,as provided for by Section 3700 of due Labor Code,for the performance of the
work for which this permit is issued. .
1 have and will maintain Workers Compensation Ieurance,as required by Section
700 of the Labe,Code.for me performance of the work fmwhich this permit is issued.
My Worker's Compen d LLt.. ce wriv and Polity number are
Cartier.'gYl1 a/LL—�[rY L/(EAgtA'e Policy No.: Z 17 8.1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlsectlw need not bccwnplcxd Rile permit is foroe hundred dollars(SIM)
or less)
I certify met in me performance of the work her which mis permit u issued,I shell nm
employ any person in any m,nnerm u to become subject in the Workers'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:IL after making this,CcrtiGnm of Exemption.you should
become subj.,to rhe Worker.Comperuation p ovideru of me Labor Code you must
.,z forthwith comply with such p nvidwu or Our permit shall be deemed rooked.
z "" CONSTRUCTION LENDING AGENCY
.N
[—i 1 hereby,affirm Cher dirt is a c. Snn lending agency for the perfwmams.f
lY the work fur which mu 6 iuw ( ee.permit
d(Sex.1097,Civ.C.)
4 Q Lender Name -
=z Lenders Address
U Q 1 cenify mm 1 bars mad this application and sum Out me above informed..u
U, f-' collect-1 agree m comply with all city and county un inamea and sum laws relating to
C) U building construction,and hereby audsodm mpresenuuv of this city to cotes upon me
4 alcove-mcnudg property for
aninspectioneexpenses
purposes
(We)egme to save,indemnify and Imp hnmless the City of Cupertino against
H ti liabiliuw.judgmcnu,cwu and expnuw which may In any way accmc aiainst said City
U z in consegoewe of the ting of mu perm'
^ APPLICANT UND ANDS I COMP WITH-ALL NqN-POINT Issued by: Date
SOURCER U r//
`> Re-roofs f �
Signmum ofApplicanVCwDam
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future Wilding occupant slum whandk hamrdow material
u 4fimtl by me Cupertino Municipal Code.Chapter 9.12.and the Health and Safely
ale.Seniors 25532(,)? [5�— All roofs shall be inspected prior to any roofing material being installed.
❑Yw
Will the. liicam or future Wilding Occupant uK If a roof is installed without first obtainingan inspection,I agree to remove
pp g p equipment or denier which P
sir District? us air conuminanu u defined by me Bay Arta Air Quality Management all new materials for inspection.
InisHodur
istric0
❑Yes
1h avereadmehvaedrms material requirements underChapke thatifthe Califon
M/CTYEGLsti••]/ �•
s ot co Safety Cade,Sections Oat it,2MY r and255i4.1 uMcrsund th CoUlu Wilding
on not cuncn0y how a tenant Writ 6 my responsibility u notify the occupant of Nc I Oat
quimmcnis Michmus bcmetpriormim Of.Cc cam of Occup Signature of Applicant Date
a OS
owns,or ovate,i sd agc DateAll roof coverings to be Class"B"or better
11/02/2005 16:31 7075267663 PERMIT SERVICES INC PAGE 14
NOV-02-2905 1131 0LD ccUN7RY ROOFING 4007823301 P.09/15
• Gemmuoiry Dcrckopmmt
10300 Toac P.veoue
Cuperoao.CA 95014
ir7wa — TeleptKcu(40 )777-3223
CITY F Fax(4088)777-5333
CUPERTINO
_ ,Building De axtment
UG ADUR'ESS: PER-MT-r Nos DD
I cr!_\ NTAn iac�G : nLiaC-40U I PHONE
S am not using an•y SubcO.tltC�Ct 'r3: Ll-V- O
O JJ
Signa;vre Date
azjl�g'olc s1:I>renrtactors an_u complete the faUawingLnfonnaden:
^` SUttC(_1NTI..f.CTOi'. �CISI.N'ti35 NA1NIE BUSINESS LICENSE it
Cerrent Finishing
� I F12CC7Cc11 —
1 Excavalion
renting _
Flooring: CizpeLing
Wood
Heating
j I.-Isulation
I ,, Lt:nd�scaping�
Or!owc 11W Me no
I I vlaeonr.y _
Plemhr inE -.._._._ I .I
Septic Ttuir,
i 511ect Motel
L51"cet 1_od< _
Tilc
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ON-V ec/C 1 tractor.si6=tuTc r Gate
Community Development Department
Building Division
City of Cupertino
Vaal
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
U P E TIN 0 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: k,4,�
Job Site Address: X06
Roofing Company Name: � C
Applicant's Signature: •L_ .1R. �K._, Date:
J� Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF 0S_W 5.6/(
OF
CUPEIITINO PERMIT APPLICATION FORM
APN # 3 `wt 2 — 1-1 - O O S Date:
Building Address:
Owner's Name: Phone#: L 5 Z X 6 7 6
Contractor 19 A9 Phone#: License#:
v/Ap -) T2- 53 o
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles �IP Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
>i To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Com ly With Cu ertino's Tear Off Policy:
Job Description: 7 o CaP7�
CdA° & D 0
Residential'- f 'Commercidl ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: a, Type of Construction: Occupancy group:
�d0 v
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
1 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING