05060006 (2) CITY OF CUPERTINO a
BUILDING DIVISION PERMIT CCINTRACTQR INFORMATION� s'
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT NO 05060006
• OWNER'S NAME: PERMIT ISSUE DATE
KE
NE:
SANITARY NO. CONTROL NO.
707 86 -
ARCHITECTtENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION
i C I hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
<at wido Section 70(07 of Division 3 of We Business ian mfessiodc, ty license'
i«Iform
Gaz:d` r3 9 L x ns OOF W/DURALITE SHAKE TILE
-p Dam 7/'AITn3r--Con11 Z
_
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records \�
Dyu
''o Licensed Prefessional
` g OWNER-BUILDER DECLARATION ,�/
if I hereby alarm that I am exempt from the Contractor's License Law for the V
00 fallowing reason,(section 00315,Business and Professions Code:Any city or county
W=[ci which requires a permit to consumer,alta,improve,demolish.of repair any structure
prior m its ismance,aisu requires the applicant for such permit to file a signed statement
F?a that he is licensed pursuant to me provisions(if ns
f Ne Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
¢t-u (commencing with Section?000)°f Division 3 of the Business and Professions Crate)or
ii mat he u exempt therefrom and We basis for We alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3.M`19801bber00 Occupancy Type
not mom On Ove hundred dollars(Is00).
I,as owner of the property,or my employees with wages as Weir sole compensation,
will do We work,and We Structure is not intended or offered for sale(Sec.7060.Business
and ProRssions Codc:The Commam's License Law docs not apply In an owner of Required Inspections
property who builds or improves thereon and who dmasuch work himself°r Wreugh his
own employees,provided War such improvements are not intended oro0emd for sale. L
however.We building or improvement is sold within one year of manPlemer,the owner-
builder will have We burden of proving that he did oat build or improve for purpose of
salt.).
1,as owner of We property,am exclusively contracting with licensed contractors to
consumer We project(Sec.7006,Business and Professions Code:)The Commcwr's Li- _
cense law docs not apply to an owner of property who builds or improves themon,and
who comeacts for such projects with a contractors)licensed pursuant o We COmanor's
License Law.
❑1 am exempt under Sec B&P C for this moon
Owner Date
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCompen-
aramr,as provided for by Section 3700 of We labor Code,for We performance of me
work for which this permit is issued.
�rXI have and will maintain Worker's Compensation Insurance,as imnixd by Semlon
190 of We labor Code,for me performance of We work for which this permit is issued.
My Worker's Compens ren lnsumnee carter and Policy number are:
�r6 4
Camcr:�N'X LATE OFEl Poliry FROM
WO (S' �_CERTIFICATE OF COMPENSATION
NFROM WORKERS'
COMPENSATIONINSURANCE ,
(This section need not he completed fire permit is foro°e hundred dollars($100)
or less.) ,
1 cent fy that in the performance of We work for which this permit is is tied.I shall not
employ any person in any manner so as w become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Cenilicale of Eacmption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you mus
v,Z forthwith comply with such provisions or this Perot,shall he deemed bevelled.
7-0 O CONSTRUCTION LENDING AGENCY
(+ Ihereby affirm that Were is a construction lending agency for We performance of
!Yi We work for which this permit is issmd(Sec.3097,Civ.C.)
aQ Landers Name
Z Lender's Address
U Q 1 motify that I have read this application and stat,mal the above information is
IT, F cored I agme to comply with all city and county ordinances and trate laws relo ng to
C)U building construction,and hereby authonne representatives ofmis city to enter upon the
r� above-mentioned pmperty for inspection purposes.
(We)agree to save,indemnify and keep harmless We City o(Cupenino against
F"paj liabilitieajudgments,costs and expenses which may in any way sector.against saidCity
UZ in ennugmnec of We granting of th' permit. _
APPLICA NDERST D WILL MPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULA
Signature°f Applicanr/Cnntractor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building occupant ams,or handle hazardous mnenal
as defined by We Cupemnn Municipal Code.Chapter 9.12.and We Health and safety
Code seainnzss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
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
it hazardous air comaminants as defined h,We Bay Arca Air Quality Management all new materials for inspection.
❑Yes Lk�
Ihave mad the h
ehusrequirementsunder Chpmr695ofinCal
ria Health&SafryCoak,Screr25505.2553soid25530J undersundOcnild
ir,
elms not currently have a nem,Out itis myresponsibility m notify themupant of
We
rcyviremens which must be met prior to issuance of a Cenifice.of Cmvpkvq. Signature of Applicaift Date
Owner or authorized ascot Date All roof coverings to be Class"B"or better
CS/30/2005 09:12 7075297663 PERMIT SERVICES INC PAGE 03
MAY-31-20' 10 09 OLD COUNTRY ROOFING 4037828301 P.01/01
- - ' - - TC0nuou4ity Dewiopmeut
10300 Tom Avenue
Cuper'ioo CA 950I4
I- --' Telophom(406)777-3326
CITY OF. Pum(406)777.2$33
COPERTINO
'- Building Department
10Jos At)DRESS. P>;xturr#
6 L ✓1Srr- 'o 66e'o !
OWIv'F2'S NAN Ce i .I D PgnN-B 445to 8 O
X GENERAL CQNTRF,LTOR: G � �i{h��� � FAX# -Oa- p Ij
)C I am not using any =ubccntractors: . _1 1WL�'/C a 3 C 5—
Signature bate
Please check applicable subcontractors and complete the.fouowing informatioru
SUBCONTRACTOR BUSINESS NAME I BUS INESSLICENSE#
tCabinets &NVIwork
Cemen t F nish ng
Electrical
- Excavation
Fencin g
Flooring: Carpeting
Unotci:m / Wood
Glass / Glazin
Jiea ting
Iststilation
Landscaping
I T.�thi.n�
Masonry
I Chnam!ntai Sheet Metal
Painting/ Wallpaper
Pay.in .
Plastering
Plumbing
Roofing .
Septic Tsnk
Sheet Metal
Sheet Rock
We
_ X S 3 o,!!,.-
ONaier/CortractorSignature Date '
10/78103
TOTAL P.01
Community Development Department
Building Division
el City of Cupertino
Telephone:
Torre Avenue
OU
I Cin Of one: (408)777-3228
V P E kT 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 comply with the above stated policy on re-roofing.
Homeowner's Name: yir�/ D /
lob Site Address: ///c2 G zt,n /a-
Roofing Company Name: Lfo:. 2 � E=29; ,f C,
A phcant's Signature: �[ ✓J�— Date: G r O S
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
REROOF o Ste' 6a o t�
CUPERTFINO PERMIT APPLICATION FORM
APN# Date:
3 S (o - l6 — 6zo
Building Address:
Owner's Name// Phone�
e � D
Contractor: Phone: License
8' � #:
,lcP v2.�630o hzz73 /
Contact: Phone#: S Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles `,,
El Other(Specify) !II�tYLtn�. �w�a t7_U
Number of existing coverings �, Provide I.C.B.O.Report# E-.O— Z(o.S
❑ To be Removed ❑ Provide Mfg. Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: ❑
Job Description: / � � os�1. Q` ev D,," Rc �S•7 ps r___
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
Uvv
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
�z6� 17-b