03090138 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT YCONTRACTORINFORMATION:�
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT"003090138
OWNER'S NAME: 125—B GROBRIC CT PERMIT LSSUE DATE
NE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB M[CH
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LICENSED CONTRACTOR'S DECLARATION lob Description
EUF 1 hereby affirm Net I am f he Bu under provisions of Chapter Y(commencing p .
2e with Scalar]( if Di 'kion]of NC Businev and Professions Contimyliccnx is
< imm�eZ:,nae.. (2 OP REROOF
s q z Liccnu s Lie.a
Contractor D
p ARCHr ECTS DECLARATION �z
2 W V 1 understand my plans shall W used as public records
In Liccuud Professional _ at
3 OWNER-BUILDER DECLARATION
a y 1 hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7(131.5,Business and Professions Code:Any city of county
e m V which requires a permit to construct,ahcr,improve,demolixh,or mpair any nuuctum
prions its Issuance.also requires the applicant for such pemorot Gla axignedsutement
221 that he is licensed Pursuammthe provisions oftheContrctec
aoraunulaw(Chapter9 Sq. F[. Floor Area Valuation
(commencing with Section 7")of Division Sof the Business and Professions Code)or
i Out he is exempt mhcrefrom and hat basis for the alleged eminI uon.Any violation of 35921007 . 00
Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penaltyof
not mom man five hundred dollars(g5Ol). -- - - - .APN Number Occupancy Type-
0
ype .____
❑ I.m owner of the Property.or my employees with wages m their sole compensation.
will do me work,and Ne strnnum is not intended or offered for sale(Sec.7044,Businevg
and Professions Coda:The Contractor's Lianu Law docs not apply to an owner of 307 - INSULATl-ON d Inspections
property who builds or improves thereon.and who does such work himxlfor throughhii
ownemployees,provided thatatrm improvements arenotinended oroffered ronale.If, 601 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not Wild or improve for puryme of 602 - ROOF PLYWOOD NAIL
sale.).
❑I,ak owner of the proli am exclusively contracting with licensed contractors to 603 - ROOF BATTENS _
construct the Project(Sec.7G44,Business and Professions Code:)The Contractor's Li. 604 — ROOF IN—PROGRESScense law does not apply to an owner of property who Wilds or improves thereon,and
who conuacts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License Law.
1 not exempt under Sec. B&P C for his reason
Owner Date _
WORKER'S COMPENSATION DECLARATION -' -
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a COlolkam or Consent to self ins m,for Worker's Com pont
kation,u provided for by Section 3718 of the Labor Cod.,for the perrann na of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,ass required by Section
3710 attire labor Cone,forde performance of the work for which this permit is issued.
My Wriker's CCo/mpeygssaI. lnsumncc cooler and Polley num ta, am:
Gamier: Y 4L�///fP� Po'icyN a-y_
CERTIFICATEOFEXEMPnONFR M ERS'
COMPENSATION INSURA E
mtix,minion need not he mora le¢d iphe Permit is forms hundmd dollars(11101
nr Ices.)
1 lenity Nm in the rerformanec of the work for which this Permit is iv u.d.l shall nut
employ any rerun in any manner an as to become subject a the Workers Co ria mation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL arta making this Certificate of Exemption,you should
Wcomc subject to me worker's Compensation provisions of the Lahor Code you must
�z fonhwi to comply with such provisinv or this permit shall W deemed revoked.
L0 CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a comuuctinn lending agcmy for the performance of
x the work for which this permit is issued(See.3097,Civ.C.)
QUnder's Name
5 z lender's Address
J Q 1 ccnify that I have read Nis application and sive this the above infonnatiun is
s.F correct.1 agree to comply with all city and county oNinancek and some laws refining to _
Z) (_) buiw-monniwniro,and hereby authonaempreunutivaf Niscirylo enter upon Ne 0. shove-mentioned propene for imnify an purposes.
� (We)agreeto save,indemnifyes hickhayinan the Cityof uCupcnst id Citn
liabilimics,judgmcnts.cosvand cxpcnsm which they in any way attrvc against vid Cily
$ consegoenee of the gaoling of this permit.APPLIC NT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date7r/�7
SO REGULATION ./qq�� ) /1
�IwAjz 7✓ Y-11 Re-roofs
Signature of ApplmmyContacon Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building Occupant store or handle to,ocous mmcoxl
as defined by W Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code Section 25532(a)?
❑Yes pfin All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha>ardom air contaminants in defined by the Bay Arta Air Quality Management all new materials for inspection.
"vier? —/
❑Tis LyTu D
Ihave real me hovaNuus materials myuircments under Chapter 695 of the Wilding ( J
ria Health&croly Code,wrom at
fl is my and255J4.1 W modify be n xonvi.1 the /r//ff
deck n rcmly bass:a engin at itis sac nce or a bility m notify the Occupant of the Cr��/1#g
rata which mo prior to issuance of a Ccnlrcam Occupwy. J Igo eof Applicant `} Date
/- 03
0 mer oranthonvedagcnt Date All roof coverings to be Class "B"or better
Building Division
10300 Torm Avenue
Cupertino.CA 95014-3255
Telephone: (408)777-3228
CITY O F= (408)777-3333
CUPF�TiNO
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
Wand 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)
pproval3) 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.
MPORTANT:
1. Flat roofs must have a minimum of V"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: /UC cy C L/f--J Pn7 e�?"
Address: 5 K/ 2 W I /t)
Reroofing Company Name: C C"/L)
Applicants Signature's Date:
Joe Antonucci
(Chief Building Official)
6/25101
CITY.OF CUPERTINO
REROOF o , ° ( 3k
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
-46P6 W1 A) Leg))
Owner's Name: Phone
/-F C.-/ C 1 d A i6rh /-i l &/o Y`t 6 a 9 d'3
Contractor: Phone #: V O License #:
Oma, Cout1� 20or'InJG +FL� rkC00 C�aa 7-31
Contact: Phone #: c! O R- Cupertino Business License #:
e,a F-3a0 Ro3 (PI
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.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: C' O✓ G- C=>ctS-t i1 v 5H p Kc:S /NSTX--rte- o S CF 15C>WF,e
-4- L- 1 1'2T1 ('-t0ew7t-
Residential Commercia ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are an re tctio Lf
ost of Project: Type of construction: \ Occupancy cup:
Qty. if
Applic 1 Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Ener BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING