03040134 (2) CITY OFCUPERTINO T �a,�
BUILDING DIVISION PERMIT Qi\ ' VTV�l I1l�,A'�,O iMAT�TON
B�7(YJIIN6DDFEACHTREE LA OLD COUNTRY ROOFING ....No03040134
I
T"IINL�IpAnRK HSU 125—B GROBRIC CT PElolrr8"Te ]0/2003
ONE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: . BUILDING PERMIT INFO
BLDGBLECT PLUMB MECH
l� = 1�
LOO LICENSED CONTRACTOR'S DECLARATION JobDescription
F I hereby grim that 1 are licensed under prndsiorta of Chapter 9(commencing p
9� in'Secdgn 7")of Division3 ofthell"ineaaendRbfeuimu Code,•dray limsmeu
in fan fc,Zaaa erz
z umnx'el - Lie.g 73 REROOF ��
z= Dau Can
FF
ARCHITECTS DEC TIO � �/y _
�S K I undersand my Plana theft he used ss public rccnw J '��l\p
a
;Q Licensed Professional
�`
`gy OWNER-exempt RDE DECLARATION V
d e I hereby reaso .(Scc That 1 1. exempt from the Contractor's is License Law for the
OO folloo'Ing 7(DLS,BaalMaa and Improve.
demolish,
e Profession Cane:Any city Os reserve
s$ which requires a permit ma cnntrun,slur,improve,h Permit torrile a sigma
ir.ny,wduro
�Ny prior m its issuance.p rsuaalso rcquims the
ovisiappo s o for sucContractor's
crow L w(Cha mem
pp xx< That(commencing
wit pursuant W the provisions of the a Bminur.f d Nor la...Carlo)or Sq.Ft. Floor Area $10��tlOn
y+f-O tham he
exe pt unsfSectroo7000)os,Divisionaifor of liteogedexe andon.An vit GMe)or
$ That he u exempt therefrom and the bssu far the alleged exemption.Any vlolalion of i
Section 7071.5 by tory applicant for a permit wbiecu the applicant to a civil penally of 3 IAOINM"cr0 0 Occupancy Type
not mom than Aw hundred dollars(55(70).
0 I,as owner of du property,or my employs with wages u their war mmpeesadon,
will do the werk.and the structure isnot intended or offered for We(Sec.7044,Business —
and Profession,Code:The Conmmofs Lienee Law don not appy u an owner of 3 0 7 — INS ULA'JW d Inspections
prepeny who build,or improves theeeon,and whodoes,uchwark himself ortuough his
awn employees.provided that such Improvements;tee not Intended aroRered for We.lf, 601 — ROOF TEAR OFF
however,the building or improvement i,veld within ane year or mmpletion,the owner.
Wilder will have the burden or proving this he did not balm or Improve for purpose of 602 — ROOF PLYWOOD NAIL
sate')' 603 - ROOF BATTENS
0 1.as comer of the property,am exclusively contracting with licensed mnuecues w
construct the project(Sec.7014,Business and Professions Code:)no Communes Lt. 604 — ROOF IN—PROGRESS
cove law does not apply W an owner of property who build,or Improves Hereon.and.
who cortracu for such prejeeu with a cenuuarry)licensed pursuant W the Contractor.
License Law.
0 1 am tempt under Sec. .B&P C for that room
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby&farm under peony,of perjury arc of the following declarations:
I have and will maintain aCerdficau of Cmuent w,elf-usu,e for WorkefsCompen-
Satian.u provided(or by Section 3700 of the labor Code,for the performance of the
oak for which this permit is issred.
0 I haw and will maintain Worker's Comperu&tion Ina.,u requited by Section
7]00 of NC lever Code.for the perfo ncc of the aster which Nis permit is issmd.
M Workers ore nJ.sloesIn ma ariicnnd PClb/y.`umber art:
Ce f %AXE/✓ Policy ..: zZ02
CERTIFICATE OF EXEMP ION FROM WOR
COMPENSATION INSURANCE
(Thu xctlm recd notbecompleted if the Permit is raronc hundred dollars(SIM)
or leu)
1 certify Net In the performance of the wok for which Nis permit is bared,10.11 not
employ any person in any mwnerw as in become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ceniacate of Exemption,you shoum
become subject to On Worsces Compeaution provisions of the Leiner Coat,you muse
Z forthwith comply with such provision or this permit shall be deemed ranked.
Z O CONSTRUCTION LENDING AGENCY
"pro Ibemby affirm Nn thew is construction lending,lemr for the Performance or
fs1 s7 the work for which this permit u issued(Sec.3097.CO.CA
W QLender's N.M.
7z Lender's Address
U Q 1 aenify that I haw read this application and sues Our du show information is
W F' torted.I agree to comply with all city and coca Inxuo end sute laws relating m
DYJ buildagcm.muction,andhembyauthoried prcsen tirp al Nis citym cutworm flu
W .hove-mentioned propeny,far Inspection 0.
(We)A'
,' dcmnify an kce Isis the City of Cupenino against
,0 liabilities,lull ,caau dexpettses Fin WCCity
t)Z CO an
o Lingo is iL
r. A IC De Ar Alp WILL COMPLY WITH LL NO • OINT Issued by: Date
50 G y
Re-roofs
Si$.Xuxof Appli r uC.MmCI Date
HAZARDOUS MATERIALS DISCL SURE Type Of ROOF
Will the applicant or future building Occupant urc w Mndle havardous material
as defined by the Cupertino unieipal Code,Chapter 9.13,and the Health and Safety
Code.sacuonss7uan �w All roofs shall be inspected prio to ofing material being installed.
❑res
Will the apphcws or future building occupenl use equipment or devices which If a roof is inst thou[ rst o i ng an inspection,I agree to remove
mit wrardous air conuminan ss defined by the Bay Area Air Quality Management. all new ma ria for' Spectl0 .
District?
C)YC.
I hav ard,msmw:n5.2553 n der Charter
rsurat95orthe Gldin,
niaHwl C ,Sretiw255o5,2557 574.Iumkrsutm thuifthe wilding (/
docs c nlly lu &Imam Wt' mibility W dry tit opwt or the
m v h met min an c n tae or gnature of Ap ' ant Date
owmeraewhotir<a I Date All roof coverings to be Class"B"or better
Community Development Department
a Building Division
d' City of Cupertino
w 10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
CUPEI�T]NO0
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: 1 1 ,,l)G
Job Site Address: cl;�(� f 3 w �L��GNB 12G%L C�4)Lr
Roofing Company Name: CCL� Q-OU/V r24 0O!'t^JG
ApAIic,,nls Signature: I Date: y- g— 3eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO O 3 o 12 l
U1 REROOF
•
CUPEI�TINO PERMIT APPLICATION FORM
APN# � ' G c0 3 O 6- � Date:
Building Address
Owner's Name: Phone#:
lti)6 K i le1<, 14,3 c4 q o' 6?6-6 Sfi
Contractor: Phone#: 41 (9 F License#:
OL (LO URh-d:Z ez0 r-t&G R3 o0 6 as 3 r
Contact: Phone#: 'f c P Cupertino Business License#:
iF v? o o
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
X Asphalt Shingles ;;K Asphalt Shingles
❑ Wood Shakes Cl Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) Cl 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 Com 1 With Cu ertino's Tear Off Policy:
Job Description: tZC-' c-M0VC�X<<S_i�t G ,2 L�-/�yZ9 of coo-
lNs�•
Residential ® Commercial ❑
Fire Zo Yes❑ No ❑ Confirmed wit nning Dept. if
there are restricts s: IJ
ostof Project: Type of Construction: Occup cy group:
Qty. if
Applica e 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
4( 73 1�
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