02050143 (2) OF
CI BUI
BUILDING
DIVISION O PERMIT CONTRACTOR INFORMATION:
"J-�'W MD ANGE BLOSSOM DR OLD COUNTRY ROOFING PERMIT NO. 02050143
OVftj JE:VIRGINIA L 125-B GROBRIC CT AW5c7fn5/n'62
I PHONE (707) 864-5557 SANITARY NO. CONTROL NO.
y O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
aV V BLDG ELECT PLUMB MECH
N
N i LICENSED CONTRACTOR'S DECLARATION ]Ob Description
1 hereby affirm that I am recited under provision.of Chapter 9(commencing REROOF
2_toq with Section 70)0)of Division 3 of the Business and rressionx Code.and my license
is in full force andeffec T/0 1 LAYER SHAKE, INSTALL CERTAINTEED
m 6
:e License Class [� I.1c,b
;Dau Date Contractor `3 / 50 YR PRESIDENTIAL COMP
t a 0 1-
E: DECLARATION a
I underatis nyrthgXl+e -f'pas publi r cond nt
1 O O Licensed Poch,...Tiiiall
OWNER-BUILDER ECLARATIO
�' 1 hereby uffirnt that 1 um exempt from the Comraclni s license Law for the
t- ¢ following mason.(Section 703 1.5,Business and Professions Code:Any city or county
E F O wInch requires a permit to construct,alter, mpmve demolish, p y pirtmie
3= poo t 'u ssInt 4 the i
applicant lot such permt I signed snovionam ------
that
---thatM1 islicensed p uap the Provisions of the Courranor's License Ice (Chapter 9
(commencing ithScction 7" of Division3dtheBusnes. dProfessions Code) -(,j .Sq (
. Ft. Floor-Area,, . -, ,� , _ ation
or that he is cumpt therefrom and the basis for the alleged demption.Any violation ' v s-. (.,'(. ;, ! A I s
of Section 7031.5 by any applicam Into permit subjeax the applicant to a civil penalty-
of not more than five numbed dollars(5500). 3 6(AVNQ1&i4kIb&W Occupancy Type
❑I,as owner of the property.or my employees with wages as their sole compensation.
will do the work.and the structum isnot intended or offered for sale(Sec.7014,
Business and Prnretsimms Code:The Comramnrs License Law does not apply to an R ired Inspections .'
owner of pmpeny who wilds or impurities mes=on,and who does such work himself 3 07 - I NSUL, I b
or through his own employees,provided that such improvements are not intended or 60
.1 — ROOF TEAR OFF'-
offered for sale.If;however.the wildhi t is sola within one ear of
completion,the uwneabuilder will have tie burden of proving shot he did not build or - "n
improve lin purpose of sale.). 602 ROOF PLYWOOD NAIL
603 -- ROOF -BATTENS
co I,as owner m(lhe p(Secny,am Business
a contracting with
ose:)sThcomnemtx m - -" - - .i .
aomswn h=Project(sec.]town Business and .,who ills or the Contractors s 6O4 — ROOF IN—PROGRESS ..
and who
Law docs.,it apply wan owner of.emny who balms o Improves menton,
and who contmds.fL such pmjens with n comractor(M licensed pursuanLto the ... ..... .. _ _.
' .. .. . .. ..... ...... .. _. _ .. ._. .. . titin. .
01 m exempt
Liccndelaw.
_ ❑Imo exempt under See. ,B&PCfor his rcoxon
Own Date
" fir WORKER'S COMPENSATION DECLARATION �®
Ihereby upmm under penalty of perjury one of the following declamtiom _ •�� rpk
❑ I have and will maintain a Cenifcam of Consent to self-insure for Worker's
/ Compensation as Provided for by Section 37W of the Labor Code. for the
r performance of the work for which this permit is issued.
ID I have and will maintain Worker's Compensation Insurance,as sequined by Section
3]00 of the Labor Code,for the performance of the work for which this permit is
issued.My W her,Compensation Insurance carticr nd Policy numberism
V
Carrier: �d ✓�i tPmlicy No.: 'ZVA
CERTIFICATIONOFEXEMFr10N FROM WORKERS''„
COMPENSATION INSURANCE". .__.. t_ .,.. . .-.._._._.I_...__.___...__....__..._........_.__._.__..__._.___. ._.__. .. __ ......_ ___.._ .. _.
(This stiction need not w complmed if the permit is for one hundred dollars -
051W)0rless.)
1 certify that in the performance of the work for which his p:,.it is issued I 1 • - �,1 -- i'
:shall not einploy any person in any manner so as to become subject to the Workers
Compensation laws of Califmnln.Dare
Applicant _ . . . . .__ .. _.. .. ._ .. _ ... . .__" __.. .... .... _.. _ .
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should - - t •'
Q 0 become subject to the Workers Compensation provisions of the Labor Code,you must
ttforthwith comply with such provisions or his petmm shall w attmed revoked.
N. - '•CONSTRUCTION LENDING AGENCY
a.J I hereby mfon that there is a construction lending agency for the peri mtarce t
Cr Lender,Name - ],Civ.C.)
mf the work for which this permit is toed(Sed,309 I
Q Lender's Name" _,a . . .._ ... . . .. /
k. Q 1 certify that 1 ply with
his city
and county
and store tont the above information its �_—
W-Utobuild I acme to comply with ell city and county ordinances and side laws upon
r) the id,oingcnnswctionandhereby,far' authorlx porn enmtivcs of this cityintoner upon
the ewvemcmimncd propcny for inspeaio puryout,
(0.k)agree iosave.indemnify and O harmless the City of Cupertino against
Vl liabilities,jodgm a and ex ns nth may in any way carve,guinn said
V'Z City in corse ce o he grad of - permit. 1V/
APPLICAN No STAN AND f.LCOMPLYWITH'ALL Dv-Po r' Issued by: Date
SOURCE N. S Yi
Sigimurec APPlle Contractor. :" - .ie. Re-roots
HA]ARDOUS MATERIALS DISCLOSURE
WillmepCu e t f on ec h f tort handle n d atonal Type of Roof ._ _.. . .
as boned by theC sem fi al Cod Ch pt 9 12 and the Beach a safety
Code,Section 25532m) i
oY. No All roofs shall be inspected priorsto any roofing material being installed.
Wi- theapsllca t wt (dingoccupantuseequipment rd ices which If a roof is install i[hou[firs[obta' mg an inspection, I agree to remove
emit hmnrdous air cootamimntEssdefii by the Bay Area Air Quality Management
Di...icn all new mate s for inspect_io . A icant understands and will comply with
'Dues, all non-pit s e regula ' ns: -
�, - .,.
]'have read he ham do amods requirerrii3�xi, odor Chapter 6.95 of the
California Health&Safet e.S etiom 2550.-25533 ml 25534.1 understand that
ifthe building amesnot mly mammon mit' ny responsibility to notify the -lJ
occupant of the req emu w it must ct "to issuance of Cenifica 0f
Occupancy. _ ..
Signature of A lean[ Da(e
Owner or affhorimil ag<m - - arc All roof coverings to be Class "B"or better
., ... .:.. . , _ .. OFFICE
-.,-
t: ,,4,.,_ Building Division
. 10300 Torre Avenue
./ Cupertino,CA 95014-3255
Telephone: (408)777-3228
CITY OF Fax: (408)777-3333
CUPEkTINO
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
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 of 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: rl�✓S/h4 ✓/ S
Address: 7 r7 ✓G1 rJ4G />�✓/Ss�r`
Reroofing Company Name: G
Applicants Signature: Date:
Joe Antonucc
(Chief Building Official)
6/25/01