03080169 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORjNE0RMATIQN 41
BUILDING ADDRESS: PERMIT NO.
OLD COUNTRY ROOFING 03080169
a O NA REEKLINE BR PERMIT ISSUE DATE
125-B GR02RIC CT
(707) 864-5557 12
SANITARY O. ROL NO.
7h1rct,I`c.
ITECT/ENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
0 0 s 0
LICENSED CONTRACTORS DECLARATION1 e by affirm that I am licnnxd under provisions or Chapter 9(commencing f� (� ^ fI J ription
fen]D01q of Divi-ion3of me Bu4 :,Omd Professions Code.and my licence is p U`f(j�I prn , r t. `/_ /65g iceCiea uc.n REROOF;,, cenv or FEB 1 0 2004
,uJ \� ARCHITE CLARATION
I C< Yv round or,plans shall be used as public records
>a U 1a�
'off Licenced Pmfcssional BUILDING Il��p�t}�
g OWNER-BUILDER DECLARATION BU LD NG
<S 1 hereby affirm that I am exempt from the Contractor's Liecox Law for the
-O o following reason.(Section 7031.5.Business and Professions Code:Any city or county
<m ff which requires a permit to construct,alter,improve,demolixh,or repair any structure
q�'^ prions its issuance.also requires the applicant for such permit In rile a signedslatemrd
=�<
that he is licensed pursuant in the scar the Contractor's Llecnse Law Cha ect9 S Ft. Floor Area Valuat on
par provision ( ol q'
e F o that be is cab with Section and the
D osis N th me Businessroil Profess mi nJc)or
i
that he is eacmpt mcrefrom and the boos for the alleged exemption.Any violation of _�r2l704r nn
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
net mom than five hundred dollars u50a. - - - -- - - - '-- - P Y - ---
❑L as owner of the propcny,or my employees wit walla as their sole compensation,
will do the work.and But strvnms is not intended or offered for sale(See.7061,But,., 305 - FRAME Required Inspections
and Professions Code:The,Contnctors Liccuee Law docs not apply to an owner of q p
pmperlywhe builds or improve-thereon,and who does such work himselfor trough his 307 - INSULATION
Own employees,provided that such improvements are not intended or offered for cele.It, 601 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion,the owner-
builder will have Be burden of proving Rom he did not build or improve for purpose tit 602 - ROOF PLYWOOD NAIL
sale.).
❑ 1.as owner of the property.am exclusively convecting with licensee cunoselons to 603 — ROOF BATTENS _..
construct the pmkct(Sec.704,1,Business and Professions CW.:)The Contractor's Li- 604 — ROOF IN-PROGRESS
sense Law dors not apply to an owner of property who builds or improv Roemer,and,
who contracts for such projects wit a eonmetor(s)licensed pursuant to the Convactmr-
Licenoe Law.
lam emmpt under Sec. B&P C for this session
Owner Date
WORKER'S COMPENSATIONDECL RATION .. ...
hereby affirm under penalty,orperjury one of me following declarations: .-
1 have and will maintain a Certificate of Coment to self-insum for Worker'sCumpcn-
-moon,as provided for by Section 3703 of the Labor Code.for Roc performance of the -
work for which this permit is issued.
ID I ban and will maintain Worker's Compensation buurmos,as required by Section
1700 of me Labor Code,for the performance of the work for which this permit is Lasued.
My We ker,,'slIC. Ir_maati1on lnsuramz cTanicrats��Pr,Iot nu/Tbcr am:e
Carttcr:LN�AyaRK lLq lOrt LMC. PyMty No.: aT I,SO�-1-
„��(JJ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This cemien need not becomplacd Rate,permit is fm tine hundred dollars(SI00)
,or less.)
1 cenify mm in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner son as In become Subject o the Workeri Compensation .
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become Subject to the Worker's Compnuation provisions of the Labor Coue,you must
z forthwith comply with such provisions of this permit shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that mere is a con-truciion lending agency Int the Performance of
Z me work for which this permit is issued(Sec.3197,Civ,C.)
Lender's Name _
1 1<nticra Ad drcx
� z
J Q 1 cenify that 1 have read this application and sox that the above information is
.L F correct.l agree to comply with all city and county ondintences and sum laws relating to -
�U building comWetion.and hereby sulooriae represenutives of this city to enter upon me
above.mentioned properly for marieetlnn purposes.
y y (We)agree w save.indemnify and keep harmless the City of Cupertino against
h liabilities.judgments.costs and expenses which may in any way acerae against said City
J z in consequence of the granting otos permit. (7
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATIONS.
Re-roofs
St a e of ApplicamrContracwrDam
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will the applicant ser future building cecupantsmrc or handle harardoue matend
as defined by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Sccdon 25532(1)? {�/ All roofs shall be prior to an ins ected roofing material beim
❑Yer SdNu rooP P Y g beinginstalled.
Will the applicant or future building occupant use equipment or devices which I If a roof is installed without first obtaining an inspection,I agree to remove
I.Lq
t hazardous air contaminants as dclincd by he Bay Arca Air Qmlity Management all new materials for inspection.
uicfl
❑Yes �Nn
IhmereadmeI mWtmsmaterialsmquimmcnuunder Chapter6.95ofine Califar-
Heatt&Safety Code.Sat:6.257(15,25533am 5M.1undersand Romifine building 8/fib/ d
s not currently.have a tenant,Lou it is my mapmrsibni y w troy Ur occupant of the ✓ Y�L��P
i uwhim must be tp�orwissu sofa Ccnifcam of 0.c awry. 1,
nature of Applicant Date
.umnn.ad agent ,e All roof coverings to be Class "B" or better
Building Division '
10306 Torts Avenue
Cupertino,CA 95014-3255
Telephone: (408)777-3228
C 0O Fax: (408)777-3333
CUPERTINO
Building DeparAnent
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 YV 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: _'Tc-%ivn/13 L. L Cl—
Address:
Reroofing Company Name:
Applicants Signature-7 Date: '::z -7 a 3
Joe Antonucci
(Chief Building Official)
�zsrol
CITY OF CUPERTINO .
REROOF o 3 G
m
cUPERTINO PERMIT APPLICATION FORM
APN # 3 6 a 9 �7_ 04 Date:
Building Address:
+?_ cam`=&�Ku Nc- i .�
Owner's Name: Phone #: G So
a?GUNIs 4,.6!a�' 0Q S6-- ,Fx
Contractor: Phone #: License #:-
O c,• C-.o c4 o or-t
Contact: Phone #: Cupertino Business License #:
L%53 CTu 1/1rt q 8-a F 3 0 0 02 0 <
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X 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.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: +'-?&M 0V ot= SHe;rlGcl I ST,;r� CL-L�5
3 O -4t7 (2O 4- C c�ef--rA I N?C-E n:> L t 1%5-,7-1 G✓/tY Goy
Residential Commercial ❑
FireZone:Y\ ❑ No ❑ Confirmed with Planning Deft. if
thele are an - trictions: LJ
Ctof Project: ! Type of Construction: Occ paiicy group: \
9 Oo0 Y_ f4
Qty. if
A Lica l'�, Fee ID Fee Description 'Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUU-DING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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