05010160 (2) • CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,10 '` G RATO"NFORMATION $1.
.I�Tn `�'+ 'wc..el u �fi..:k'P?.•�'
BUILDING ADDRESS: OLD -COUNTRY ROOFING PERMIT NRb5010160
OWNER'S NAME: PERMIT ISSUE DATE
la 11 NOELLE PAQUET 125-R GRORRIC CT 01 /27/200c;
ONE: SANITARY NO. CONTROL NO.
(707) 864-5557
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� (�
u o 0 LICENSEDIL IamRecorded
underCONTRACTOR'S DECLARATION Job Description
W I hereby affirm that 1 am licensed under provisions or Chapter 9(commencing p
with5ttuon 7IXX)of DivisionJof tie BuSnev and ProfessionsCotle.and mylim"a is .®
u in full force and cff 21.1 p q
5'q= can. �'4 Contractor 6 REROOF W/COMP. IGCan/
z r w Dam s Conuacer
ARCHITECTS DECLARATI
asU 1 understand my plans shall he used as public records 7] py,,•y1
'' < Licensed Pmfcssianal �QO(S ��•
in OWNER-BUILDER DECLARATION
Y1 herchy affirm that I am exempt room the Contractor's License Law for the e
p O following reason.(Section 7031.5,Business and Pefessions Cone:Any city or county (iX71
which bmuirms a Permit to container.alter.Improve, bronlish.w repair any structure
Prior a its issuance,also mquiex the applicant for such Permit to file a signed itsNmem
FSO that he is licensed pursuant to the pmvisimmofthe Contrachn'sLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
mH (mono Ocing with Section 7000)of Division 3 of the Business and Professions COda)of
y $ Wt he u except mer.froe and th,basis for the alleged caampuon.Any violation of
Sccdm 7071.5 by any applicant for a Permit subjects the applicanuo a civil penalty of e10 0 Occupancy Type
not ewe man five hundred nonan(S5U0). P Y YP
❑I,as ower of the PePmy,or m"inn't yw wire wages as their seto compcnsanan. (j
will da he work end theswmum is not intended oroRcsnd for sale(Sec.toad,Business pp Cgnr lip
and POstrum v Code:The Conmcmr's Lianse law does not apply m an Owner of RegUlr vdf a tl nS L B@
property who builds or improv Ihcrmn,and who does such work himself ar through his
Own employees,provided that such improvements arc not intended at offered for sale.IL
however,me building or improvement is sold within one year of completion,me owner- MAR n gapt�
builder will ban the burden of proving Nat he did not build or improve for purpose of MA L L u
sak.).
❑1,v owner of me property.em exclusivelyd convecting with:)The
contractors m Try U q ®� ,w,,�
moss La the project(Sec.told,Business and property
Prowho
Code:)The C t berean, Li- �t®J/ L n$H 'vel,
cove law docs nos apply o an with
a of property who builds or improv thereon,and `R2
whocontractsUw.for such projects with a cmnVYlpr(s)licensed pursuant to the Convectors
License Law.
El I em cacmp,under Sec. .B k P C fw this wan
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm undef penalty of perjury one of me following dttleadmia:
I ban and will maintain a Certificate of consent to self-insue for workersCompen-
satOm,as provided for by Secuan 3700 of Or lobar Code,to,the podiums.of the
work for which this permit is issued.
have and will maintain Worker's COmpevation I...as eilmoud by Section
3 00 of the labor Code,far dm pcRarmantt of the wart fw which mu permit is issued.
My does ComPycp)sadooninsutan¢camerand Policynumbcrane:
Caries �.Y LI/YL/.ON Polity No.:
CERTIFICATE OF EXEMPTION FROM 0 KW R ERS'
COMPENSATION INSURANCE
(Thu section need not In completed if tk Permit is foronc hundteddollars($I00)
or less)
1 eenify that in me performance of the work for which this permit is issued,l shall nos
employ any mown in any manner so as m become subject to the WorkersCompensation
Laws of C.lifomix Da¢
Applicant
NOTICE TO APPLICANT:If,after making his Cerificae of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Code,you most
.JO forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
Fw= I hereby affirm that there is a construction lending agency,far the performantc of
the work fur which this panni,is issued(Sec.3097.Civ.C.)
117 Lenders Nam.
z Lenders Addw
1,Q I ttnee o c I pave cad this city
..it coup and sots Net Inc above infweation is
C)U building I agree to comply with all city and county ordinances and state laws relating e J(/
C.7 abovengeononed! on.and forvbyeumon p mpr.sentatives of this city menhir upon the
abovementioned!pep costs
far ex a uses which
y
F y (W.)agree to nw,indemnify and keep harmless the City of Cup.nino against
rZ liemoscCClUmex .n¢casesendOf this Pewhim may in anywry attec againstsaid City
V z APPL CANT UNDERSTAOf Out NDS AND WILL CPMPLY WITH AL NON-POINT Issued by: Date
SOURCE REGULA
7/"3 Re-roofs
Signature of Applicano'Conuactor Dau:
HAZARDOU MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
u defined by the Cupenino Municipal Code.Chapter 9.11.and the Health and Safety
wle,Scotian zsslxap
❑Y m All roofs shall be inspected prior to any roofing material being installed.
Will thea scant Orfatue Wilding Occupant t ordevic.s which If a roof is installed without first obtaining an inspection,I agree to remove
pp g p aAuQn
it ha>ardous air contamivnts as defined by the Bay Arca Air Quality Managemcnl all new materials for inspection.
taint?
[]Y rla--
I have med the hvaNnus mmerials requimmenu under Chaper6.95 of me Califon
nia HcalN&Safety Cad<.Sttuov 15505.15533 and 2553x.1 undcrnand thwif the Wilding .I 27
docs not warently hart a tenant.mat it u my responsibility a notify the occupant of me
eyuimmcnta which
prior to uancc oft Ccnihcam of Occu cy.
I T Signature of Applicalft Date
as
Owner or mun.n.d age DA All roof coverings to be Class 'B" or better
12/14/2004 13:37 7075237663 FERMIT SERVICES INC FAGE @--
NN-25-2005
3TAN-25-2005 10:13 OLD COUNTRY ROOFING 4OVS23301 P.03
Commmiry Dovdopm w
10300 Tare Aveaue
Cupatino CA 95014
Telephone(408) 777-3228
CUPEOF
IZTINO e,u(aoa)77t-333
Building Department
JOB ADDRESS: PERMU#
� .5''O cm5 rorc ✓z d 5 C) l O 1 6�
OWNRR'S NAME: o�L1 cF /:Pt4a PHONE* 2 08 3 R f%
GENERAL CONTRACTOR OenFAX# �► g o
I
I am not using any subcontractors-- 1
Signahu'e Date
Please check applicable subcontractors and complete the following information;
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets&Millwork
Cement Finishing
Electrical
Excavation
Foncing
Flooring:Carpeting .
Linoleum/ Wood
Glass/Glazin
Heating
Insulation
Landscaping
1 �
Masonry
Ornssmental Sheet Metal
Painting/ Wallpaper
I
Paving
Plasterin i
Pltmtbi:tg
Roofing
Srp+ic Tank
Sheet Metai
Sheet Rock
Tile
Owner/C.ontractor Signature Date
2
12/' 4/2094 13:37 7075237E63 PERMIT SERVICES INC FAGE 02
JAN-25-2995 10:0 OLD COUNTRY ROOFING 40e7228321 P.04
Community Development Department j
PUU0.1n8 Division
City of Cupertfno
10300 Torre Avenue
Telephone: (406)777-3=
CUPEkTINO Fax
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to peratit issuance.yuu mutt agree to comply with 1997 LTBC Standards
and manufacturers sped£cations on re-roofing.
2. New roof coverings shall not b2 applio ri without first obtaining all incpoctinn
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 folluwing swpb are
required-.
1) Pre.impeetion and/or tear off approval.
2) In-progressinspecdm approval.
3) Final inspection approval
a) Spark arrester irutallation �
S. if plywood b installed,a plywood nail inspection is required.
• 6. Any roofing which is applied witlurut first obtahting an znspec,tion,
will regtritt the removal of all new material down tto'the sheathing,
so is.proper City i-,epeetion caul be performed.
1M RTANf 1
1. Flat roofs must have a minimum of 3'4" per foot slope and dtmlomtrate
that there is no ponding.
2. An 1.C.B.o.report is required to be on the job site at the time on inspection
1 understand and will comply with the above stated policy on re-roofing,
Homeowner's Name: _jpj J 4!f-t-U� �/) 14 c5!i�
Job Site Address:
I
Roofing Company Nas�te:r — C el UNT r r X00 r- 1 IV6
A plicanfsSignatures 1 j;jtj=gw2Q Date'
�.t�K1J�Di)O
Greg el
Building official
Revised 1/30/03
RkiOed on RW/&W Pear,
TOTPL P:e4
G CITY OF CUPERTINO 0 / u ( ( O
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN 436 Oy ,-';' 017Date:� 7 -7 /os
Building Address:
r ?O
Owner's Name: Q Phone#:
I �s3 - V7qg.
Contractoro, p 9 Phones g:g -7b� �3ov License#: G Z.Z _7 3 /
Contact: Phone #: 4a.v Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles '19, Asphalt Shingles
)4• Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide LC.B.O.Report#
ATo be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
3/0 'a,/M4,
/0p
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: od Type of Construction: Occupancy group:
/O 000 -2
Qty. if
Applicable Fee ID Fee Description Fee Group
/ BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING .
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
0/
70.