04050139 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CUITRA.CTURNFI'}ILMA.TIUN't
BUILDING ADDRESS: GROMO ROOFING INC PERMIT"°04050139
109'12 WTT.KTNq(-)N AV
OWNER'S NAME: PERMIT ISSUE DATE
CONNIE CHI
ONE: SANITARY NO. CONTROL NO,
(408) 746-2075
ARCHITRCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 PETI
LICENSEDMe,Iam ONTRACIOR'SDECLARf Chap
U I hereby affom Nn 1 am of
Business
i..do,provisions of Cheerer 9(commencing Iib D05CITpnOn
with SectionS'701111)ec Division 3 of Nc euvressentl Profcuiom Code,.and my liccnu is
n�N infull
onCla nticrfea y 3 Z P 7 T y REROOF
j�? Lken.Cls Le 3 �/' LIc.N
�t p Data -- ��Comracbr / " '
s ,�� sh ARCNI'IF.C'1'S DECL9 ATION v
Y 1 understand my plans shell he used as public records
�yU
Cleaved Professional
OWNER-BUILDER DECLARATION
E 0 0 1 hereby emrm that 1 1. exempt from tbe Contractor's Co License Lew for the
4❑O following mason(Sectiw 703 a ,,Business and ce.d Professions Code:Any city or county
$ which requires a Permit re quires the
elan Imprasu h Permit to
file
repair ed swcam
prior miuissuance.
cnwdpunu requires pm applicant for suchmtm's Lic asUw(Cammcm
E�C (commencing
cing wit pursuant mum pro vision of Nc Contsiness Liccnu Law(C ode)or Sq.Ft.Floor Area Valuation
x $ (cammencixemith Section701and
ndth Diviciofr thbribeMesad Business pt Professions Code)of
Nal he u exempt Ncmfrom and the buts far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjaut me applicant to a civil penalty of 3 563430"erO O Occupancy e
oat mom than five hundred dollars(MOO). P y '7 P
❑I,uownu of the property,or my employes wird waguu donsolccompen.tion,
will do the work and Om.actum is notinknded oroffemd forsale(Sm.7044,Business
and Property
obu Coon:Them trscmr's License Law dart or apply lf an rough is Required IUSpeCUOn
own ertywhob,provids or ed Mand Nemonve ants Mwhodue not Mounted
Mmseeared(rough his '
own a however,
Me v,provided mastich improvements as not arDf m kern,Me ow.H,
however,Ne building or improvement is hold within one year of completion,Ne owner.
builder will have the burden of proving Net he tlld not build a improve for purpose I(
ole.).
Ic
❑1,uawvrofuseproperty.amexclusively Professions wird:) anCcanoacmrsi.
construct the project(Sec.o an Business and property
whoo builds
Code:)DanCopernicus'sMarcos,
Lid
taloa law dote not apply a an owner of property who builds ar improves Coman,end
who cantata for such proje<ta wird a conoecmr(Q licensed pursuant to the Conoadors Q
License mLaw.
❑tem exempt under sec. ,Bd:PCfor this auto
Owner Dao
Ah WORKER'S COMPENSATION DECLARATION
I hereby
air
antler Penalty of perjury one of Ne following declaauons:
1 haw and will mwnuin a Certificate of Consent to self-insum for Workers Compere
.tion,as provided for by Section 3700 of the labor Code,for Ne perfmmalme of the
work for which this Permit is Wind.
WI bow and will maintain Worker's Compensation In.r.ce,as required by Section
3700.f Ne Labor Code,for Ne pedormanec of the work ftrwhich this permit is iuued. -
My Workers Compensation Insurance canim and Policy number are:
Cartier: T7'I Y& C✓i✓C Policy N91 aF5- //r�
.� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
(Dissection need not be completed if the Permit Is portion hundred dollars(SIM)
or leas.)
1 certify that in Ne perfurmanec of Ne work for which this Permit is issued,1 shall not
employ any Person in soy mammrm as In become subjael to the Workem'Compevetion
Laws of C.lif.mi..Data
Applicant
NOTICE TO APPLICANT:If,after making this Condition or Exemption,you should
become subject in me Worker's Compevation provisions of the labor Code.you must
OftMwidt comply with such provisions or this permit shell be deemed revoked.
Z ^' CONSTRUCTION LENDING AGENCY
[r I hcmbyafllrm Net Nem is a coneouctlon lending agency for me perfurmarme of
!Yi> Ne work for which this permit is intend(See 3097,Civ.C.)
W Q Lenders Name,
]z Lenders Addmas
V 0 L certify Nat I have mad thin application end stale Net the be.infmrnubm is
W F correct 1 agree to comply with all city and county ordinances and sure laws minting to
0 U building construction,and hereby authorise representatives of this city to enter upon the
[A
above-mcnuonted dgmrropertyst for inspection purpWhich May
V
(We,)agree I.mm.indemnify and keep burble.Ne City of Cupertino against
ti V liahilitiu,judgmcnu.cmu.tlexpcn.s which they in any way second against svd City
C)— APPLICAcNTcUNDEof Me RSTANDSunning of IAND WILL COMPLY WITH ALL NON-POINT his permit. Issued by: Date
SOURCE REGULATIONS.
.r-21-may
` Re-roofs
Signet afApplianUCono etor Date
1/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne,applicant or rumor building occupant store or handle havardous material
as defined by Ne Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
ode,Secure 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Egoi
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
it hamrmor air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disoict'
❑Yes AN.
In ave mad thc h=d4)us mamrialsmquimmcnu under Chaprer6.95 of thc Califon
nia Hcalth&SafetyCadc,SmdomMO5,25533md35534.lundn=dNatiftie Wilding
Mx*no,currently have amoan.that it my mmonsibility m witiry Ne reentrant or Ne
mquirements which must be met prior to issuance ore Compute or Occupancy. n
Signat YeofApplicant Date
owa�rtr eamtrived agem Dam All roof coverings to be Class "B"or Better
i/
Community Development
` 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
SCITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDR SS: P IT #
C53Z L--/ r.ifi a i lF 0 Y f0/J 9
OWNER' ME: rd i. y C f/r9 PHONE Yo Pl SrG-20 7 f
GENERA CONTRACTOR: c2o,r,) iyoDam/NC I Y r . FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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 C d si0 0 /ti
Septic Tank
Sheet Metal
Sheet Rock
, Tile �
e /Contractor Signature Date
10/28/03
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
SAM CITY OF
Telephone: (408)777-3228
qUPE R.T I N O 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 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: e 2 �. lv�/yY // i9�✓c
Job Site Address: /e9 9�7 L �4-/ 1 t< /i1'r 0 v_
Roofing Company Name: !�/z Y U 2"40,0f/"2/ C
A plicant'sSignature: Date:
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
I�T
CUPEINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
/ b 72 w/L /NrOiv /f v4 .
Owner's Name: Phone#:
e'a/vn y c///.gJ7/6 (yon/ z rZ —�J/i?
Contractor: Phone#: License#:
6-/t0rso lzea cl yr 1-c. C'/oi) 7y ? )677y
Contact: Phone#: Cupertino Business License#:
�2//ivc/Tp (yos)y SG 9
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles g Asphalt Shingles
fd-'Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
,d To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description:
/CC%do"d , S//9 K 1, /iv r,71L a p.I Er/Yr..-rle /Z PO O'� TUiv 0/-/3 WJop
Residential 1,9 Commercial ❑
Fire Zone: Yes ❑ No 0 Confirmed with Plan ' f
--� there are an nctions:—
Cost of Project: Type of C ruc ' Occupan group�
Qty. if
Ap ab] Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit FeesBUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
TEE
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