05100031 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT x CONTRACTnRINFORMATION °;
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BUI LDING ADDRESS: OLD COUNTRY ROOFING PERMIT No.05100031
11077 LINDA
OW NER'S NAME: PERMIT ISSUE DATE
CHRIS COPELAND 125-B GROBR10/07/200S
NE:
SANITARY NO. CONTROL NO.
(707) 864-5557
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X01LICENSE DCONRACTOR'SDECLARATION
C 1 Mmh,affirm INt 1 am Iia ed under provisions of Chapter 9(commencing - ,.1�_,S,rl
ZZU with Section7Myof Division Jof the Businecsand Professions Code,and my license is d rg
:?n in tall Tome and cop, 9 L1eM 2_2 731' % REROOF-T/O TILE, RESHEET OSB, ADD COMP.
y6j? Liccnu Clu J
nt-n Dam '1 Contractor D . NOV 3O 2OUS
ARCU 1 unacrsonJ my pit�na;H iS DEC j ch �I y Y�1
k LicensedLicenud Professional •••////���e ��%II vwwarw�� -- g� II
S
OWNER-BUILDER DECLARATION
<f I hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 71171.5,Business and Professions Code:Any city or county
$ which requires a Permit to consumer,eller,mr,row,eemalish,err .repair any nmerum $13000
prior to its issuance.also sequims the applicant for such permit to rile a signed statement
<
that he is licensed PurhiI.theprovitium,ofNcContractors LicevcLaw(Chapter 9 Sq. Ft. Floor Area Valuation
'Ho (commencing with Section 7")of Division 3 of the Business and Ptofanions Code)or
y Nn he u eumpt mhcrtfrom and the Dssi+for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant a civil penalty of r Occupancy Type
not mom than Eve hundred dollars($500).
I,u owmr of oe pmpeny,or my employca with wago u Noir mlc eompenution,
will dotheworts end theswctomistees Laaeac Law
(Sec.7064,B.of -
pro erty who o Coe:The Conuacmrs License Law dao trot apply lf an.ours is Required Inspections
property who builds or improves Nampo,and who ams such wart himself or through his
own employees,provided that such improvements in:not intendedfcmoRercd formic.wner.
however the have
the
b r den of cot,sat he didn o, year ofcompletion.of r go purpo ner,
builaer will Dave Ne burden of proving mu he did not Wild or imprint for purpose of
sated.
0 I.as owner of the Indian,am eaclusim), i ntracti.,wilt licensed antractors to -
construct the project(Sec.7066,Business and Professions Cade:)The Communes Li-
cense law ams not apply n an owner of property who Wilds or improves thereon,and,
who contracts for such pmjecss with a contracmr(a)licensed pursuant to da Conuactofs
License law.
❑1 am exempt under Sec. .B&P C for this reae.n
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty or perjury am of da following declarations:
1 hive and will maintain a Certificate of Continuo self-insure for Workers Compcn.
satin,as provided for by Section 37W of the Labs Code,for to Performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Intra¢,ss nquirea by Section
7W of the tabor Code,for the performance of tM work for which this permit is issmJ.
My Wosketag,",yContra..dQn Insupanmynier dna Policy number a rt:
Carrier.rY`/6-a IJ JR I CATEOs'ETIsMPTTliq IHO 'O K3S'/t
CERTIFICATEOFEXEMPTION FROM EORKERS'
COMPENSATION INSURANCE
(This scnfon need not W completed If da:permit 0 Poronc hundred dollars(SI W)
or ten.)
1 certify that fn the pcif...of the work TO,which this peemit k issued,I Nall nut
employ any person in any manner so m in become subject to fhc Workers Compensation
Laws mf California.Dam
Appliesnl
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the LaWr Code,you must
.,O rordwith comply with such provisions or this permit shall he deemed mwkcd,
Z CONSTRUCTION LENDING AGENCY
F< T hereby affirm that them is a construction lending agency line the performance or
Cf..�-r the work for which this permit is issued(Sec.3097,Civ.C.)
IU Q Lender's Name
=z Lender's Action
U C) I certify that I bars mad Nix application sM sone that the aWw information is
gy P c.rtccL 1 agsce to comply with all city and county ordinances and sc a laws misting to
0U Wilding construction.and hereby authamempresenotived of this city to enter upon the
' W above-mentioned property for inspection purposes
(WC)agree to Nye.indemnify and keep harmless the City of Cupenma against
liabilities,judgments,costs and expenses which may in any way aeaue against said City
U z in consequence of the gram'.,of Nis per it.
.-r APPLICANT UWRSTANDS,A LL CO Y WIjN ALL NON-POINT Issued by: Date
SOURCEREG ION /
erF l0/7/sg Re-roofs 46f�
Signature o AppyiunUCo motor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser fumrc DuilJin,mcupant Wore or handle havaMaus material
u defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
cWe.s brei 155310)? All roofs shall be inspected prior to an roofing material beim installed.
❑Yea �- P P Y g g
Will toe applicant or future building occupant case equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hmardnus air contaminants as Jcfincd by @c Bay Area Air Quality Management all new materials for inspection.
District'
❑Yes QNu
I have read the honard..snnu rials racRunce ems under Ch t,ter6.95 of Ne Calif., a
niaHwlth&SafctyCoM,Sections 2T3(15.255JJ and 255Jd.lunacntand thmifthe Wilding ,a /
docs not currently batt s tenant.Nan it u my rap.mihility m notify Jp asupant of mW
mquirements w ch must ee mctpi (issuance acemfieac.faaapa. . Signature of Applicant Date
a 9 All roof coverings to be Class "B" or better
Own gr#Y - Dao
Community Development
10300 Torre Avenue
Cupertino CA 95014
- Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: 1/0 7 7 PERMIT#C-)51 0 0 0 "3
OWNER'S NAME: jPHONE # — G
GENERAL CONTRACTOR: a FAX#
I am not using any subcontractors: 0/ad �i - - / -2 /os
Siggn,afure Date
Please check applicable 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
Community Development Department
Building Division
City of Cupertino
�! 10300 Torre Avenue
CITY Ofl Telephone: (408) 777-3228
4U P E f�T 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.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
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 comply with the above stated
policy on re-roofing.
Homeowner's Name: C�KnnC�Ca�,
Job Site Address: II 77 pp /� C w (�7Qy L�JiI
Roofing Company Name: C7 Gt 1 u vCti I`�l� �l
Applicant's Signature: e� Date:EQS
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION FORM
APN # 3 S 6 ,O (0 LS Date: /0 / 7 / o S
Building Address:// D 7 -7
- R'a.. V.L Z�,
Owner's Name:� pp �� Phone #:
liGt
Contractor: n9 Phone#: License #:
0 ��t LEA _792 -S3o o 2X] 3
Contact: Phone#: Cupertino Business License#:
Sc?,.c 7
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)aPA,'a6% ❑ Other(Specify)
umber of existing coverings ❑ Provide I.C.B.O. Report#
To be Removed ❑ Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Co�ply With Cu ertino's Tear Off Policy:
Job Description: 7—/a O S (5 5o Lp 9
Residential 1 p Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: Ll
Cost of Project: so Type of Construction: Occupancy group:
13 oov
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
3 6� 2-
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