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BUILDING DIVISION PERMITCONTRACTQRINFORMATIQN
BUILDING ADDRESS:
141-1 RTAmpnRn PT
OLD COUNTRY ROOFING
PERMIT NOO 4050088
OWNER'S NAME:
PERMR ISSUE DATE
R
-114/
ONE:
SANITARY O. C NTROLNO.
408=9V=95 yo
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ARCHITECr/ENGINEER:
BUILDING PERMIT INFO
•
ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Chapter 9
pp come, Job Descri tion
IL V v e- p
1 Wmby affirm that 1 em licensed under previsions of (commencing
-M
with Section 70N) mf Division Sof the Resinauand Profcsskns Coda, end my license is
kfull mmeandeffen.
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3 Loc. g 22 3 I
REROOF aN COM e" 30# Fe IT
Lkcnse
ra
Data ore o
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my Ian al _u
G� S
Limnutl dcuionel
OatNEB-BUnER DECLARATION
D
I hereby affirm 1 em exempt from Ilse Contractors License Law for me
n
lowing mason. (Section 11131.5. Business and Poressinv Code: Any city or county\/
whish requim a permit to construct, aIle; improve, dcmoluh, or repair any structure
prior In its iuuance, also requires the applicant for.uch permit to Ne a signed statement
Ft. Floor Area
Valuation
thetW ielimnmd puauemmthc pmviairna of the Comrmmrs License law (Chap¢r9
Sq.
(commencingwith SmOoo11100)of Divisions oftheausin.esandvi Codd tar
that he is exempt memfrrm and the bub fm Ne alleged eump0on. on. Any violation of
3 592.2 c* 0
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects me applicant to a civil penalty of
not mom than five handed dol Ws (ML
_
1,uownerof tis employees withwagerutheir Sok a
Required Inspections
,Burdon,
doemny,or t
will dthe work and thehe C.n Isn,inLedd forsake (See 1044,owineu
Lt.
Coda; The Conhumr's License Law docs ret apply lf rt owner of
and Profession,who
emywhe Wild. does inchwork his
ld.
aroffrorthmugh
,provi,impmmch Impr,endwho
awn employees, provided mal such lmpreveamts em not Intended m mA for
own
oamer.
Ne Wilding or improvement I. sold within oro year or mproe far the nose
la
of
Wilda will tive me WNm of paving mat he did not build or improve fm purpose of
Wilder
�
tale.).
Q
❑has an, of property, am exclusively Pronasions with Ikuued mnhutoa k
the project (pec. toad, and Code:) lis U.
crew ct
improves and
La weer of property who quarter, rt
rove law docs notchapply loan owner of property who Wilds or ant
to Commie
who coronets for such projects with a conlncm,(q Ilcensed pursuant a the Crnvacmrl
License law.
❑ I am exempt under Sec . B d P C for this mason
Owner Dam
r .t
WORKER'S COMPENSATION DECLARATION
1 hereby erf rm under penalty of Perjury am of one, following declarations
I lave and will maintain a Cenifcate of Consent to self -insure for Worker'. Crmpen-
udon, as previdd fm by Section 3700 of the Labor Code, for the performance of due
for which Nis permit is issued.
�wA
gt have and will maintain Worker] Compensation Insurance, u required by Section
7700 of me Labor Cod, for Ne performance of the work for which this permit is issued.
My Wmker's Camlwvation Insurance carrier and Policy number am:
WC- /
Carrier. A4rZ UA/AW AM Policy No.: Lq'_2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE l=Xj"I
(This sectkn need not becomplesd lithe Permit Is forme hundred dl an; ($IN)
or leu.)
1 minify that In the performance of the work for which this Permit is issued, I Nell not
employ anyperson in any manner an as an become sedjecuo the Workers'Compsnation
-
Laws of Cal l moa. Data
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject m the Worker's Compensation previsions of she Labor Code, you must
foMwith comply with such prevbiov or this permit shall be deemed revukcd.
CONSTRUCTION LENDING AGENCY
I hereby effort Wt inert is a mvtraction lending agrees, for the performance of
the work fur which ones Permit b issued (sec. 3091, Civ. C.)
Lender's Nun.
Lender's Ad.
I ready that I have reed this application and sac that the shove Information is
'
Ponca I agree to comply with all city and county oNinanm and sus laws relating he
Wilding convection, and hereby euonodre repromm tim of miscity in cater upon one
alpve-mendrnW property for inspection purposes.
(We) egrte to save, indemnify and keep harmless she City of Cupertino against
It b11i0v.I dgmen ,Pmts andexperues which may In any way accnsagaiml said City
inconsequence egaating of this crani{,
APPLI "A DERSTAND A W L L ITH ALL NON DINT
Issued by: Date
SOUR[
Re -roofs
Type of Roof
_
s /
Si of ApplimHQAuacmr Dao
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or ruture building occupant store or handle hmudaus material
as ditned by the CuFartlna Municipal Code. Chapter 9.13, and the Health and Safety
PaleSection sss3z(a)1
All roofs shall be inspected to any roofing material being installed.
❑Ys �Nu
prior
If a roof IS installed without first obtaining an inspection, I agree t0 remove
Will the applicanl or future Wilding occupant use equipment or device which
mil havudnm air cmdamimmu ss dinned by the Bay Area Air Quality Management
all new ma Is for inspection.
isnict7` ',
❑Yes
Ihe,. read the huallouSmaterials "Whereas Inti, Chaps, 6.95 of On Cattle,-
10,vx�'�r`ur
iallezlm& etycodo,5a9ov 25505 j33 d25534.1underslerWmuifmcbuiliing
v
m ml by have a ren e u y p lot icy m "it Ih xe pw of
gntre ,mrh_ma5t_h c 5 ce .0 Emmrramp Pr.
/S' nature of Applicant Date
All roof coverings to be Class "B" or better
authorized agent m
a
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
i 3 �T �'oz � c L.
PERMIT # GD
OWNER'S NAME: lUaArrc r1i'0n)
PHONE # p �13 o0
GENERAL CONTRACTOR:O� Cvy /Zoor-,ur,
FAX# Y9F P30(
I am not using any subcontractors: &AYE6 - /a- oY
Signature Date
Please check avvlicable subcontractors and comnlete the followinv infnr nti nn -
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
0 f CCU" 2_0
o J
Septic Tank
Sheet Metal
Sheet Rock
Tile _
Owner/ Contractor Signature
Ja— /J-cy
Date L
5aC U /
IkCITY OF
UPEkTINO
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
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 Y4 " 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: rK 1 G f f r-l� _-�) d-�z O 3 1 /VSo/Q
Job Site Address: -�-g 13 S'r/g lOr-c S�
Roofing Company Name: VL�P GOUn� �LQ<Dl JG
A plicanYs Signature:
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
Date: (5- /ate_ 0Y
amy
CUPEkTINO
CITY OF CUPERTINO
REROOF
PERMIT APPLICATION FORM
APN #c33
Bld Permit Fees
Date:
S-
BENERGY
Energy
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Building Address:
Seismic Fee Res
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BSEISMICOM
Owner's Name:
BUILDING
Pone
t Gl i o littTon�
BUILDING
`f c L r S�fo
Contractor:
Phone #:
cense #:
1 ctW Q0F ,VG
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Contact:
Phone #:
Cupertino Business License #:
c s
Yoa F3,0
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03 cp
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Roof
❑ Built -Up roof
Asphalt Shingles
X Asphalt Shingles
❑ Wood Shakes
Cl Wood Shakes
❑ Wood Shingles
❑ Wood Shingles
❑ Other (Specify)
❑ Other (Specify)
Number of existing coverings /
❑ Provide I.C.B.O. Report #
XTo be Removed
❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply
With Cu ertino's Tear Off Policy:
Job Description: KCt r lovct CAr"e�0 /NI�P o IT Fel--j
4 - I— I
c= (,) i f7 oni
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑
Confirmed with Planning Dept. if
there are an restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
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Adnl"hle
FPr In
Fan
BPERMFEE
Bld Permit Fees
BUILDING
BENERGY
Energy
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSEISMICOM
Seismic Commercial
BUILDING
BPLANCHK
Plan Check Fee
BUILDING
BUSLIC
Business License
BUILDING
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