03060094 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,tCOIVT.RACTURIrNF.O„ RM�1. �IN
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMITN.O3O6OO94
0 NER'SNAME: 125—B GROBRIC CT �RMIT'�F?n2/2003
PAVENHORST HENRY AND MONA
)NE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uC LICENSED CONfRAMR'SDECLARATION Job DescriptionuesUlu _ '. O
u 1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
will
Section TOM)of DhMdon J of de Bualnwand Profeasiov Code.and my license is
TIL mmBlure eClesenarrrtc _.y '1 REMOVE EXIST. LAYER .OF COMP, IN�Lo D��# 'VELT
Lq Diamn Con gracmr
ARCH ECTSusexur ATI AND ELK 50 YEAR COMP.
I underwnd my plans shall he used as public records BUILDING
56
go Licensed Professional
OWNER-exempt frDECLARATION
F 1 hereby asso affirm on 1 1. exempt from the Cssion C's License Law for tw
S0 o fallowing Charon.(Section]IG L5, t.aiteu and ow,de ry Code:Any city or county
$ which mqulrcs•permit re construct.eller,hnpmsu demolish.ri e a sig any statement
MetIs,slieco issuance.also requires Me forMe Conpermil mfilcasLvtlsmamcm
< (comma licencedpursuant mthcofDiviovoftheContsinces Licevelaon,Codar9 Sq. Ft. Floor Area Valuation
3
(commencing is exe exempt
Section 7(0())the
basis
r M the Braine mnle rm.ProfMy vi Code)or 8 0 0 0
Nal he u exempt fere(mm and Ua bss4 for the alleged eamption.My violation of
Section 7071.5 by any applicant for a permit subjects the applicant to•cisll penally of APN Number Occupancy Type '
act more than raw hundred dollars(SSW).
36914006 . 00
❑I.a owner of the prrpeny,or my employees with wego a their mle compensation,
will dathe minesk.Codec he Comisnnss Licedaraw ed doesfor o,apply 70 an wnerof Required Inspections �p� ���
and Prolamines Cade:The Conhencon,License Law don or apply lf rt Ower of 305 - FRAME q P
property who buildsserimpmvv thempn,and who are,nsuchwork arafffedforWehfs
awn employers.provided or I prowmempmwmentsaa ans eandedoraRered for Couper. 307 — INSULATION
forwent.Neave thgarimpmwmentisrot as did act year of Imp. foron.da owner. JULU gd 2003
builder will haw the burden of proving that he did wt build a improve for purpose of 601 -. ROOF TEAR OFF O L
a1e')' 602 - ROOF PLYWOOD NAIL `'
❑I,vawrcroj fepmpeny,em emess and conhanin,with:)The Cronoamasb 603 - ROOF BATTENS BUILDfftlG
0 1.as the project(prop 7016,Business and Pmfesalav Codeli The Convector's to
ave law does not apply man owner of property who wilds or improm Museum.and, 604 - ROOF IN-PROGRESS
who contracts for such projects with a contractor(s)licensed p umant m the Contractors '
Lieeve Law.
m
l aaemPL under Sec ,Bd:PC fee Ws aamn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pevlly of perjury one of the fallowing decanUov:
1 lmw and will maintain a Cer iftaserf Consent m sel6imum for Workers Compere
cellon,u presided for by Section 5700 of the labs Cade,fa de performance of the
work for which this Permit is issued.
❑1 haw and will Chairman Worker's Compensation Insurance.as required by Section
5700 of the Labor Code.for the performance of the work for which this permit is Issued.
1/] My Workers Compensation Insurance artier and Policy number ant:
1/ Cartier: 5 r 4 F�IVn Paltry No.:16' 7Y d7/
�" CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
rl7rmactlon need not be canphred Iflhe permit Is finenehundmd dollars($10()
or ICs.)
I certify fat in do performance or the work for which Tis Permit Is issued,1 Nall not
employ any Perron in any manner an a in become subject to the Workeri Compewtion
Laws of Califomia.Daa
Applicant
NOTICE TO APPLICA M..If.after making this Ceni0cea of Exemption,you Nauta
become subject to the WorkeM1 Comper atian provisions of fc Lahor Cock,you most
=0M
fowith...Ply with such psrosin nes w deemed avnk
this Permit shall be cd.
zy CONSTRUCTIONLENDINGAGENCY
1 hemhy aRrm fat Pert is a avuuetinn lending agency for the Pcrfurmancc of
> the work for which this permit Is issued(Sec.YM,Civ.C.)
Q Lenders Name
=z Lender's Add.,
J O I senify dal 1 haw rem!Tis application and atsa that the abow information is '
•y conoci.I agree to comply wit all city and county ordinances and sora laws misting to
building cora ructian,and hereby authorise rep esenmiwa of this city in enter upon the
ahove-mentioned property,fm ivpech fi pu"Cas.
(Wc)agree b sew.indemnify and keep h the City of Cupertino againrt
CA liebiI des,I dgmen andaperrsesw ch y nanyvnyamue against aid City
in C.C.On etc the6 in of this i
^ APPLICA U DER AN L. OMP_LY WITH A L NONPOINT Issued by:S4�� Date
SOURCE E LA /
�O /2_1403 Re-roofs
SilmarurhoAppljcan on, 10, Date T
AZARDOUS MATERIALS DISCLOSURE Type Of ROOF O CO
,� 0
Will the applicant or future building Occupant ,one or handle hvardous mutant]
ss darned by de Cuperm.F
al Code,Chapter 9,11,and the HCA%and Safety
We. ❑Ycs15571(e)? All roofs shall be inspected prior to an roofing material being installed.
Will the appR=ant or wilding«eap.nt as egaipment or devi= winch 'If a roof is installed out first Ob ing an inspection,I agree to remove
it hazardous air conumm. a defined by the Bsy Ama Air Quality Management - all new material r inspection.
vim?
❑Ye. j
I have mad the hvaNnuntsundc,Ch.Par6.95ofde C.Ilfrr. �� „ �-7
ria Hcelth@Seth .SxU53N.IunMrsmnd thstif de wilding '/`//{
does not Ca I ow one ibility m notify Occup tof de
reyoimCu v .ccni0es = Signature o pplicant Date
Owner ser athoriz agcm Daa All roof coverings to be Class "B" or better
Building Division '
' 10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: (409) -3M8
C 0 Fax: (408)777-3333
CUPEI�TINO
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 rni*+i**+um.of 2/"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: q C'W �
Address: / 03,;Zy IZ C' IISr-GJ2C'
Reroofing Company Name: _V�- p
Applicants Signatur� � u�'�--�7 Date:
Joe Antonucci
(Chief Building Official)
6/25/01
c73o(� o � q �
CITY OF CUPERTINO
G REROOF
CUPEIZ,TINO PERMIT APPLICATION FORM
APN #
Building Address: l f!J DIA—
Owner's Name: Phone#:
-I& ts'l 7toy ass - 99a�'
Contractor: Phone#: / License#: /
L i t`OL(rt}T 0
Contact: Phone#: °/o sr Cupertino Busines License#:
Tis ��a oo O 3 °l
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles '�K Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ 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 Comply With Cu ertino's Tear Off Policy:
Job Description: k3 FM O[/0- L X 0 s F/� L_,1Y cart-- o r-
/ C4
/V,.S 601*� i�c=�r -+- /c74-k SO�.L Gomes
Residential ;, Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are anyrestrictions: LJ
Cost of Project: Type of Construction: Occupancy group:
O 0/0 r-? E�00i- lZ- 3
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