03040097 (2) CITY OF CUPEwrINO
' BUILDING DIVISION PERMIT ,CONTRACTrOR,INFORMATION ;
/' AO slN WY OLD COUNTRY ROOFING PERMIT No 03040097
i� PSFON ARTHUR L AND DONENE 11 125—B GROBRIC CT PEaM ssNn/yR1 8/2003
(707) 864-5557
NE: SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Op LICENSED CONTRACTOR'S DECLARATION O O O O
FF I Wreby affirm that I am licensed on&,p 'i sof Cox W 9(commencing Job Description
?ZW with Section? )n kind. the Busiroad o Cpdo sad plyfiansc is
'6 6 in full fOKc antl 1�7O ✓✓ t� /
>�� Lima class lll��� �a / L�., REROOF /
Date CupARS -CrSID ar RATION - 6
loin f0 rsupyn MuuJ 3s public mnrUs 'J�/ y_
GN Licensed
S OWNER-BUILDER DECLARATION C`�T
ix 1 forchy affirm that 1 am exempt from the Contractor's License Law for the
O O following reason.(SCetion 7031.5,Business and Professions Code:Any city Or county
i m which requires a permit m cnnlruct,alkr.improve,demolish.Or repair any structure
Peter to its issuance.also requires the applicant for such Permit o file a signed statement
as that he is licensed pursuant to the provisions at the Contractor's License Lisa(Chapter 9 Sq.Ft. Floor Area pplYolyq6ion
2 F,G (commencing with Section 7000)nf Division 3 of the Business and Professions Code)or Y
$ that he is exempt therefrom and the basis for IW alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects tW applicant to a civil penalty of
a.lmnrc than five hundred dwmri($500). 3 5919 68021t9er 0 0 Occupancy Type
❑1,as owner of the prod,ta,ny,or my employees with wages as their sole compensation,
will do Ne work.and the structure is not intended Or offered for sale(See 70q .Business 305 — FRAME
aided Professipn Casae:The um Contrtor's License Law does act apply an owner or Required Inspections
proNny who builds Or improves thereon,and who dogs such work himselfor through his 307 — INSULATION
Own employers,provided that such improvements are not intended or offered rorsale.If. 6OI — ROOF TEAR OFF
however.Ne building or improvement is sold within one year of completion,the owner-
builder will have me burden of proving thal he aid not Wild or improve for purpose of 602 - ROOF PLYWOOD NAIL
sake).
El I,as owner of the property,am exclusively contracting with licensed contractors to 603 — ROOF BATTENS
<nmtmel the project(Site 7Dla,Business dad Prefesaioni Code:)The Contractor's Li. 604 — ROOF IN—PROGRESS
cense law does not apply w an owner of progeny who Wilds or improves thereon,and
who co miscas for such prejecu wit a convaciorrs)licensed pursuant to Be Contractor'a
License Law.
El and exempt under Sec. ,B&PC for this reason
Owner Dna
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ore Of the following declaration:
I have and will maintain is CenificalO Of Consent o ulGinsure for Worker'sComped-
1371M
ion,as provided for by Section 3700 of the labor Code.for the performance of Ne
rk for which this Permit is issued.
1 have and will maintain Workers Compensation Intanum,as required by Section
of me Labor Code,for the Performance of the work for which this pandit is issued.
Workers Con nation Inwnna artier a liry um art:rtie �I9 �✓ND - PolicY No.:n�G and:
CERTIFICATE OF E% PM17ON FROM WORKERS'
COMPENSATION INSURANCE
(this second need nut W complamd if the Permit is(nroa.hundred dollars(SIM)
m less.)
I eir ify that in the performance of the work for which this Permit is issued,I shall not
employ any permn in any manner an as to become subject to the Workers ComPensatlon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Wcome subject re the Worker's Compensation provisions of the Labor Code,you in.,,
� z fortwi In comply with such provision Or this Permit shall he deemed mvoked.
L� CONSTRUCTION LENDING AGENCY
1 hereby alarm that mere is a construction lending agency for me farformance of
Y me work for which this permit is issued(Sec.3097,Civ.C.)
LQ ladder's Name
Z Lender's Addruss v
C) I certify mal 1 have read this application and sum mat the Wve information is
y H correct 1 agree to comply wit all city and county nNinances and sum laws Waitaki t to
�U
buildingconstruction,tied onand forcbyacti np rposeunutires of this city mcmcr upon the
CL above-(We)a re to saveroperty for inspection keepha
�y (We)agree In save,indemnify and keep harmless the City of Cupertino against
N liaemsea,judgmenu,eosts and ex Or ch may in any way accrue against said Cily i `�`S
Z inwnsequc of the oil of th pc il. /�sU'
^ SOURCAPPLICAPPLICA RSTA S A WILL COMPLY WITH ALL ON. OI Issued by: Date
SOURC ULAT ✓�Ja//I
Signal fAp CanVCOruactur Re-roofs
HAZARDOUSMATERIALSDISCLOSU RE Dac Type Of Roof
Wilith applicant or future building Occupant store or handle hanrdous material
as defined by the Cupertino Municipal Cone.Chapter 9.13,and the Health and safety
Code.Section 355121¢)? \
Yes All roofs shall be inspected prior to any roofing material being installed.
] �u
Will mea applicant or future building Occupant use e If a roof is installed without fir tainin an inspection, I agree to remove
PP 6 g equipment or devices which las p
all on
air codm nano az defined by the Bay Arca Air Quality Management all new materials for ins Ion
ialricR /ry-1{yJ'g-
❑yes
I have rcaJ the haaardnusmaerials uiremcnu under Chapter 6.95 of the Califory
nice Health&Safe Ccdc,Scclitw 355(1 5533 and 355N.I mkrstand mu if thc building
does idol cu t h ve a mnanl,ma is my responihilily w no ly the acuP of
quire is W wissu one fi<ate O eO Signature Applicant Dat
Owner urmth-pso<d agent „< All roof coverings to be Class "B" or better
Building Division
10300 Torm Avenue
Cupertino,CA 95014-3255
` Telephone: (408)777-3228
CITY Of Fax: (408)777-3333
CUPERTINO
Building Department
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 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 of inspection
We understand the above policy on reroofing and will comply with this policy.
Homeowners Name: n 'i 1 H
Address: I
Reroofing Company Name: IV-I—rz�l r--�0,0 (-- (/L6
Applicants Signature: l Date: `7"—Z 6; 3
Joe Antonucci
(Chief Building Official)
6/25/01
CITY OF CUPERTINO 3 �7
O
REROOF
CARYINO PERMIT APPLICATION FORM
APN # 3 5 1 a O Date:
Building Address: 1
�-G o 1
Owner's Name: Phone#:
Hy , 1,Z o ,AD 0?6-3 7 / 13
Contractor: Phone #: y o License #:
OL.� C_00 v0 - ,,t,6 Aga ?.k3 0,) Gia
Contact: Phone #: y o 8 Cupertino Business License #:
�C— --,-L b ;;z 03 3' 9
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
A 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: Y{c=mo✓G L%XISY'� L�yc� 01- blrY-�'lLc% l ,r,4-L-� OZ6
o r c£L� 4 C_C 2-T;�q 14Tca�zi) L-1 i c'TI .?F C o + t om
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
0 00 0,01= 3
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
2
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