05030139 (2) d CITY OF CUPERTINO p�,�� 'x•`//*����ayyt*ryr��.. .^t•I Iyy�� }"�^x��y
BUILDING DIVISION PERMIT �Vl!1"LQll L1\l'-� J.,x l\s�
�4' ni:reek`.; .W -.
BUILDING ADDRESS: - OLD COUNTRY ROOFING PERMITN.05030139
MAI; r)ACIFICA MR.
iARCHITECTIENGINEER:
NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY N CONTROL NO.
BUILDING PERMIT INFO
BO EO PLO MECH
O
+lop LICENSED CONTRACTUR'S DECLARA71ON Job Description
i� I hereby affirm that I nu 11 Blued under provisions of Chapter 9(oe enumcing p
with Section7070)of Division Softhe Built and PoefeailuvC and my licawu is
0 infarccaanderten C 3 yl ?>�
': Liana n REROOF W/SHINGLES
Dam as
111--- AFICHO SDECLARATION
U 1mummundmyplatsmolbeuedupublicmanol
LmcvW Pufassloml
pa OWNER-exempt R DECLARATION
3 i i I hcmby anbm ont 11. exempt from the Castans Cod License Law for Ue
5:O O following mean.permit
1 7031.5,Business and roe.de uv Code:Any city or county
nnn
v�$ which require a n,colt re oenat dan alcor,Improve,h remit t ti repair any ulneture
F y Prior m its I1tYa11R.aWl mgalmJ dC applicant formuch PCr11111 b RIC a signed anmmenl
gg a that heulicensed pueanttothe Pmvisionsnfthe Corusnte,Uwnmlaw(Chapld9 Sq.Ft. Floor Area Valuation
on
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he 0 exempt thmrefrem and the bails for the alleged exemption.My violation of
Section 7031.5 by any applicant for a 0permit subjects the applicant to a civil Penalty Of 3 mero 0 Occupancy TYPO
not mom than w hundred dollan(53007.
❑1,u Owaerof de property,or my empioyces with wage a theirule compenution,
will do the work and tie structure 4 not intended oralfered far sale(Sm.7061,Busircv Required Inspections
and Professions Code:The Contractor's Liave m ss e ac
Law does not apply an maor q pec Q
maremywho yees,pdamlmprowshima,utdwho doeueehwmk himxelfaf through his
however.thin iprovidedrhotach ImPmwmentain ammotyear
fcell afaaved for ole.if. v
however,the building or improvement b old lea
ooe)aar of ample (a the ower-
builder will haw me burden of proving Nn he did not build m Improve frc purpose of
❑1,as,Owner of the property,me exclusively c0nrratal.2 with licensed contranmrs to
convect the project(Sec.7044,Business and Profusion Code:)The Contractor,Li-
Cents low thou icor apply an owner xe property who builds or improves thereon.and, Q
who contracts for such projea cts with acoetramar(s)lianas pursuant to the Conlranuh 0
I.kenxe Law. 3/7
❑ m e.
laexempt under ,Bd:PC far this moon pS
O,vner Data
WORKER'S COMPENSATION DECLARATION
46 I hereby affirm under penalty of perjury,ons of the following declsndons:
I have send will mainrum u CertiRcamafCOnum On self-intim for Wodenes Conium.
ntlon,u provided for by Section 3700 of the Labor Code,for the Performance of this
work for which this Permit is indeed.
1 haw and will maintain Worker's Compensation Imuran.,as required by Section
700 of the labor Cade,for the performance of the work far which this Permit is issued.
My Work aCompensation Insurance carrierand Policy number me-
Cartier. .Y Polity Nos 'r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
folia section sed not wcanptmed If the Permit Is forona hundred dollars($100)
Or lcas.)
1 cud(y that in the performance of the wart fu which this parnlir is Issued.I mail am
employ any peen in any manner sa as in become subject a the Workeri'Compemation
Law,of Califomia.Dem
Applicant
NOTICE TO APPLICANT.If.Apar making this Certificate of Exemption,you mould
become object in the Workers Compaomion provisions of the labor Code,you mum
.,O foMwilh comply with such Provisions or this permit mall be deemed rewked.
„z.�"" CONSTRUCTION LENDING AGENCY
F'"^ I hereby oflirm that them is a construction lending agency fad the performance of
(Yi the wort for which this permit is issued(See.3097,Civ.C.)
QLanders Name
]z Lenders Addoass
U0 I cenify that I have mad this application and slam the the show infoormi.u -
lj.H corrin I agma an amply with all city and county ordinances and nine taws mluting to
0Ubuilding construction,and hereby authodm representatives of this city te Owner upon the
LTi shove-mentioned property for Inspection pulpoWL
IL (We)agree in taw.indemnify and kap bundles,the City of Cupmino!gaunt
In liabilities,judgments,costs and expend which may In try way secue against said City
(„)7 in consaxpen Nc grant o erten.
f i SOPLIC UNDE D WIL�M�PLIOWIITH A O,N INT Issued by: Date
�7z °e"S Re-roofs
Signmum of Appllca el umclor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will gee applicant or fulum building OauPLOLIM or handle havardous material
u de0ned by de CupeNna Municipal Cade.Chapter 9.12,and the Health and Safely
caM.f Section
❑ . 6++� All roofs shall be inspected prior to any roofing material being installed.
r r
Will the applkut or future building accursed use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haumous air cantaminanu as defined by the Bay Ana Air Quality Management all new materials for inspection.
Diatdm7
C]Yen abk� ,,//��
I have maJ the hvaNnusmaterialsmquiremcnu undcrChapmr6.93 of the Glifor- e�r !� /�j�C
tie Health&Safely Cade,Section 23505,35533 and 25534.1 undcrmand that Ease Wilding /A1�_!�7Q+
dens not cmmntyy�yy��ow a wnanl,that mymapo IlbRitymnoufy than,occupant of the
require, Bhmy b t gag
iCeNlhworocu ey. Signature of Applicant Date
S�i�/,s
Owner urauthodand agent Da All roof coverings to be Class"B"or better
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
UPEI�TINO 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) h1-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$176.18. The re-inspection fee must
be paid before another inspection can be scheduled.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: �\ � OnnQ � I-6✓1
Job Site Address: 7,- POL6- oaa T -
Roofing Company Name: �1C(^1�0 V//D�.nil x`01
Applicant's Signature: . � L Date: 3 1 D oS
Greg Casteel
Building Official
Revised 11/2/04 .0,
Printed on Recycled Paper
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCIF Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
aD ISS PaCr�,, C Oo. .
OWNER'S NAME: PHONE # D$ a5 - oa
GENERAL CONTRACTOR: 0l6 FAX #
I am not using any subcontractors: !Q 3 1
Signattlle 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 nn DD
Owner ontractor ignature Date
CITY OF CUPERTINO
REROOF bsv 3°
CUPEf+,TINO PERMIT APPLICATION FORM
APN# Date: I
3ZPq L _ C) /0 � �DdS
Building Address:
o2p Gt � CA �-• .
Owner's Name: Phone#:
Contractor. Phone#: License#:
01 Crn,�n l e 40�v/\ �o� 7ga roaa�3
Contact: Phdne#: Cupertino Business License#:
I-ESS Saw - _
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles X Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ^A ElWood Shingles _
Other(Specify) dal., ❑ Other(Specify)
Number of existing coverings L3 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: 710 a. &,Q., . OSB. 0—clef SO�11 Cores 1
Residential ' Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anrestrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
AA 000
Qty. if
Applicable Fee ID Fee Description Fee Group
1 BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
1 BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING