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04060107 (2) 5 CITY OFCUPERTINOeffi- BUILDING DIVISION PERMIT CON TRAC�"T•,OR,�INFORMATION BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT NO 04060107 OWNER'S NAME: PERMIT ISSUE DATE Jilk VLADIM ONE: SANITARY NO, CONTROL NO, 5557 (707) 864- ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 X00 LICENSED CONTRACTOR'S DECLARATION JobD Crl tlOn wF 1 hereby affirm that I am licensed under p ov}vima nr chmic,9(commencing rs its with Sation]only (Division Sof the Busincsaan oficasinns Care,andaryliccnxis tau\\IIA E® n<n in fu 111 m,ape cif ✓/t VN (1� ;ta_ L;ce sec i tie.nom 2Z 3 j REROOF �F££p Date RCHITELTS DECr ON aeOp /NG JUL bJ 2004 C I understand my plans dull he trod as public records; DnU 3 u. Licensed Pmfessioml BUILDING- 01 ion Oat I am exempt from DECLARATION tC�U@L�5IN� iS I hereby affirm Not 1 em czempt from the Contractor's License Law for the no following mason.(Section]W 1.5,Business and Professions Cork:Any city or county m which requires a permit m therm mm,almr,improve,dcmnllsh,or repots any srnctum prior m iu iasuance,alsorequirestic applicam forsuch person lar Ole a sigod summain mmhcisliccmcd pursionuothc provision of she Comrumr's Lianx haw(Chep¢r9 Sq.Ft. Floor Area Valuation in $ (commencing with Section 7")at Division 3 of NC Business and Professions Code)or that he is exempt therefrom and dm basis for the alleged exemption.Any violation of a. Section 7031.5 by a"applium for a permit subjects the applm-I in a civil penalty of 3 8\B5130"erO 0 Occupancy Type not more than five hundmd dollars(5500). p 1,u mor of the property,m my employees with wages u their mm cmmpcnution, will do Ne work and the=n.is not intended or offered for sale(Sce.7014,Business and Protections Cade:The Contractor's License taw docs not apply to an owner of Required Inspections propenywho bailie or impmmo meson,and who dommich work himself or through his own employees.provided that such improvements are not intended or offered for sale.If, however,the building or improvement is old within one you of completion.the owner- ` builder will have the human of proving that he did rot build or improve for purpose of sad.). 0 1,as armor of the propcny.am exclusively contracting with licensed contractors to container the pmject(Sec.7014.Business and Professions Code:)The Conracier's Li. mum law dos not apply to an owner of progeny who builds or improves themon.and who contracts for such projects with a com acmrut licensed pursuant to On Contractor's Lmnx Law. ❑Iamexemptundm Sec. ,Bh PCAxdrismuon Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby alrmm under penalty of perjury one of the following declarations: 1 have and will maintain aCenificim of Convent to xlGinsure for Worker'sCompen- some,as provided for by Section 3700 of dm tabor Code,fm the performance of the work for which Nis permit is issued. 1 hate and will maintain worker's Compensation 0uurance,as required by Section 37 ofthc UWrCode,forthc We ormuccofthewarrkforwhich Nispermitisiuued. My Worker] nm a.�s/ayi mrstrom -triesand Policynumbera Casper. •'f'/ ✓ //�l"Paliry No e- /1s"z , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This.,i. it nm k<eampleval if the permit is for aro hundred dollars IS 100) or Mu) 1 certify that in the performance of the work for which this permit is issued,l shell not employ any person in any manner an as or become sobjaumhe WorkersCompensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making his Ccnifieam of Exemption,you should baome subject to the worker's Compensation provisions of the Labor CMc,you must .,O foMwW limply with saeh pmrvi.i..or this permit shall he deemed rewnked. Z CONSTRUCTION LENDING AGENCY [-. I hereby affirm Out there is a construction lending agency for the performan r of C the work for which this permit is issued(Sec.3099.Civ.C.) Lender's Name IL z Lendce:Address U Q 1 certify that 1 have read this application and sum that the above information is W r moca.I agree to comply with all city and county oNinsneea and sum laws relating in 0U building construction,and hereby authorial representatives of this city to enter upon the r above-mentioned property for inspection purposes. (•-' y (We)agree to save,indemnify and kap harmless the City of Cupertino egi irm ten liabilides,judgments,costs and expenses which may in any way license against said City U z n coma be f IM granting of Nis'm APPLICA NDERSTAND NO Y WITHA�N��Ny Issued by: Date SOURC RE NATIONS. - _ --- / schat Apphnn✓comuacmr Data Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant atom orhandlc huardans marn'il u defined by the Cupertino Municipal Code.Chapter 9.12,and the Heahh and Safety We.OYes 25532(x)3 No All roofs shall be inspected prior to any roofing material being installed. 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 mit havardous air contaminants u dcfned by the Bay Arca Air Quality Management all new materials for inspectio Distrim3 �iu71 Yes ^ — zww_�' ehvallousshoutrialsoaqui menu under Chapter 6.95 of the Cxlifor. Codc,Sec oto 3550 3 d25534.1undcrsund thatifthc lmildm9 have ant, m' y ihility mnntily Be atop with ust h ce f c.ficam of&cup. $1 azure of Applicant ate aw dagent D All roof coverings to be Class"B"or better Community Development 0 Torre Avenue lie Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building De artment JOB ADDRESS: PERMIT # 5 ,(S /'" a 7r, OWNER'S NAME: V LA PHONE # c!O GENERAL CONTRACTOR: Oma. CoU v "G FAX # VO P--3O I am not using any subcontractors: % le � — / 0 - Signature o -Signature Date Please check apphcable 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 X Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date !1 Community Development Department \ Building Division r 1 City of Cupertino "F 10300 Torre Avenue CITY OF Telephone: (408)777-3228 C U P F IST 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 `co/mply with the above stated policy on re-roofing. Homeowner's Name: V L 11 J7 I /! 7 , /1- 0 y/<'14 /-)'7,9N11 Job Site Address: I l & 63 IO iC c i Elf:( i. VG C-7— Roofing Roofing Company Name: 0 U A/-V (3/20(3 f=A plicant'sSignature: /TwX,—_�) Date:G"lo c jr Greg eel Building Official Revised 1/30/03 Printed on Recycled Paper CITY OF CUPERTINO REROOF �P CUPEkTINO PERMIT APPLICATION FORM APN # 0 6 6� 6-1 061 Building Address: I //r? Fo2c-:5-r Is- Owner's Owner's Name: one : V� fr, ©y ,J 19 Contractor: P ne - License#: ooF(Ivo Contact: ho #: Cupertino Business License #: 00 6P Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles 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. 90�1 Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: Job Description: —1 ,1- a o 7 �z2 d- L,_�L--1 _ `/o C.O r•� Residential A Commercial ❑ Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if there are an _restrictions: LJ Cost of Project: Type of Construction: Occu cy group: b P , coo Qty. if AppQbile Fee ID Fee Description Fee Group / BPERMFEE Bldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCH_ K Plan Check Fee BUILDING BUSLIC Business License BUILDING