03060093 (2) CITY OF CUPERTINO ser'» �ta
BUILDING Division PERMIT CONTRACTOR INFORMATION '
BUILDING ADDRESS: 441 OLD COUNTRY ROOFING PERMIT No.03060093
629 jA-1,499 TOWN DR
OWNER'S NAME: I25-B GROBRIC CT "` 69A/1�2/2003
F
)NE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O o LICENSED COm ACTOR'S DECLARATION
Is I Imroby"On Nat 1 Am licensed under provisions of Chapter 9(Commencing Job Description
with Section EKgI)of Division 3 of the Business and/Profusions Conn,and my license is p�
in full fora and effecte (p�?7J /_ REROOF
jZ Lieen¢CJ lie.•
nF
Dow G /L tracor T
A rT1he use DECLARATION
3 alma aha M1 u dupublic rtend AUG 11 2003
a Q y IJa Nf On
g 3 OWNER-exempt R us the Contractors ATION
200 1hmasoaffirmon1em.usinfromthesCo :AnycLawforthe BUILDING
p o fallowing rtes^..(Section](ISLs,Business and Professions douoli Code:Any city or county
m 0 which nequissuance.•permit ne ares On
site,improve,demolish,Or repair Any suucmm
iii prior mits ensed prommantto On NeapplMOf for such perrnirNecruic aw(Cha men
gg1-a Nmwiscingwiit purwam N the of
of thea,Buacmrand Prop Law(Chaprcr9 Sq. F[. Floor Area $IIVe� IOn
Y~$ (commencing ,1thouim.And
basisofr the
theegedCun Profusions Cann)of
Nat he 4 eumpl thertlrem and the aped for the cU doe currant to Any violation of
Out
e t1k.five
airy applicant for s( penult mbjeeu roc applicant to a civil penalty of 3 APIN MiMer 0 0 Occupancy rwt mone Nan five hundrtd dollars(g3110). P Y TYPe
❑1,u awnu of the pmpaty,or my emplocm with wages u Noir sok compcnudon,
will do the work and On structure isnot intended or offered for sale(Sec.1014,Business 305 -
and Pre essim"Code:The Communes U.Law does nut apply m an awMr of Re aired Inspections
property who buildsorimproses thereon.and whodoessuchwork hiresedforthrough his 307 - INSULATION
own employes.provided Our such impNvemenu as not intended oroRued(orals.If, 6OI — ROOF TEAR OFF
however.one building or improvement is sold within one your of completion.the awner-
builder will have the borders of pro.ing wt he did not wild or improve for purpose of 602 ROOF PLYWOOD NAIL
eek.). 603 - ROOF BATTENS
❑h u owner of ct pro.Trai ,B utlus and coronions with licensed cOnuuton N
conswct thees WL (Sec.toaa,Businessandrty who bud Code)i The Conhercons Li- 604 — ROOF IN—PROGRESS
come law dos Inst apply a an owner of property bow wildsrs improv Nemo.,and
who anuaeu for such projects with amnuamor(s)licensed pummm N the Conuaetota
License
Taw.
131 am exempt under S. ,B d:P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby fmn..our penalty of perjury oro of she following declantions:
1 have and will maintain•Cmdhcak of Co oma m elf-imam for Wo lker's Compen.
anon.As Provided for by Section 3700 of do labor Cods.for the performance of On
work for which this Permit is issued.
❑1 have and will maintain Worker's Compemation Insurance,as mquined by Section
3]00 or 0.labor Cade,for Ne performance of the wort for which this permit is issued.
My Wode Compe tion lnswance unie send Policy number raane:-,�� n—s
Cartier. JT �1�a Policy No.:_r_tr^_�-t.2� y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihissectimi need not be complered if the Permit is(:roes,hundred dollars(1100)
or Ina)
I curury that in roc performance of roc work for which this permit 4 issued.I shall not
employ tiny person in any manner so As In hu one abject N the Workcss'Compensation
Laws of Califomia.Dare
Applicant
NOTICEM APPLICANT:IL after making this Cenificate of Exemption,you should
become subject b the Workers Compensation previsions of the Labor Code,you most
D,z fmNwith comply with such Provisions u this PermirshaR be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
1 botchy affirm that Nene is a consnction lending Agency far On perform..of
Y roc work for which this permit 4 issued(Sec.3(Y97.Civ,C.)
31 0 Undoes Name
3.
7 z lender's Address
J Q 1 unify Nat I have read this application and state that roc above information 4
comet.1 Agra u comply with all city and county ordinances and state laws relating In
wilding comuucu...and hereby aNOnne representatiwu Of this ciry to enter upon the
C abovcmcnuoncdprepcny for ide.,mtionpu
(We)agree town.indemnify and up Ica the City of cupcnino against
La h liabilitiu,judgmcnts.eosu aM expemmw ich yin any way ucrue againnaid City
J z in eamrquen granting of Ni Pe t.
'—' APPLIC N STANDS ND L COMPLY WITH ALL ON-POINT Issued by:9Date
SOUR A NS.
la p�
sigwortorApp vconuacmr Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ate Type of Roof
Will roc OPlicattver forum building Occupant store or handle harssdous macnal
As defined by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safety
Mo.Section 25532(a)'
❑Tu All roofs shall be inspected prior to any.,.f6ofing material being installed.
If a roof is installed without firs[ob 3n an inspection,I agree to remove
Will the applicant emu bodkins.cupa equipment or devices which g P g
it Im.dou Ait contaminants u defied by ay nee Air Quality Management all new materials ( - Spectl0 .
❑Yes ❑
I harc theh Ins mnteri nemcnts under Chapter 6.95 of On Califory
niaHuldt myC .Sevum 25 33 an1],SS3a.l undcrsuM dwifthc wildin6
dors no mly�pve .ant, m ibility m noufy On:.upant of dK
Nquim 'FhKhmusl m uaaOraccnirKaleofoccupancy. Signature ofA�. icant Dat
Owner of author dagent Date All roof coverings to be Class "B"or better
Building Division --
10300 Tom Avenue
• CuPmin%CA 95014-3255
` Telephone: (408)777-3228
CITY o Fay: (408)777-3333
CUPERTINO
Building Department
Subject: Reroofing policy for the City of Cupertino.
1. Prior to per=dt 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 ofA"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: "LU 1 -r-7-1 ' (?J;5-A//A I
Address: til %S�o wAl
. Reroofing CompanyName: 0 L- D C-0 N N i wc�/ �o o
Applicants Signature: 1 Date: 6;
Joe Antonucci
(Chief Building Official)
6/25/01
CITY OF CUPERTINO 3 g�
aCITY0
REROOFCUTINO PERMIT APPLICATION FORM
APN # �3 / /C� I.P / o / e /
Q / Date:
I � l�rlo3
Building Address:
& �5 T tit es-ro w Z
Owner's Name: Pho #:
'S � I�c�iuw `�0 o? S3
Contractor: Phone #: y O J' License#: .
Vim ' BONN , r2oor /6 G 2q i
Contact: Phone#: y o bL Cupertino Business License #i
q`�kcop 9
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
>r, 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,Com 1 With Cu ertino's Tear Off Policy: �.
Job Description: >�c M 0 V L:;- L�x t STt Lir.(��+�- /ir/s rit « o s3
3 O LZ� ,L C -O 60117
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: u
Cost of Project: Type of Construction: Occupancy group:
coo C--e2.0o (= � \ 3
Qty. if
A licable Fee ID Fee Description Fee Grou
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
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