05050092 CITY OF CUPERTINO
BUILDINGDIVISION PERMIT .,CONTRACTOR INF,.ORMATION '
BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT"05050092
W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y0z LICENSED CONTRACTOR'S DECLARATION Job Des n 1
mp I hereby affirm the,I am licensed under provisions of Chapter 9(commencing
iW with Seetion 7MO)of Division 3 of NC Business and Pmfessiom Code.and my license is
„ infunm�eandc�t"3 (� zz-7 REROOF W� COMP. SHINGLES /� _
jqi License Lic.J
L—p Da¢ e C actor v7oo�
at2� ARCH) flN L
�i�e IundcratanJ my plans shallh used es puhlic records {{{�®''Tyle t[flt� '111gp���Bpg
;0� Licensed Professional
3 OWNER-BUILDER exempt
DECO CaronON
MW
00 I hereby.(Lrm on 1 em exempt from Ne Convncmrs License Law fur the
i e O following mason.(Section 9031.5,Business and Prolegions Code:Any city or county
m Lai which requires a permit it)e.also n alun improve,demolish,or repair ed atmnurt
F26 frauNslcense its pursuanttacquires prrovision of far such Contractor's
ontra toi'tofile a cense Law
Chartstalmant
that herrocinnWit pursuant to On provisions of theeeBusinas an emulsions Coda)or Sq.Ft. Floor Area Valuation
¢�� that be is exempth Section7")and f bans n 3for t f the eged exempt on.M Professionsdon of
i $ that he r exempt b tmrcfrom and the bur for the alleged exemption.Any violation of �Ar��wi
Section than veairyapplicantrotapermitsubjccutheappl¢anuaacivilpenaltyof 3ppy�CbWbQr0O Occupancy Type
not more than five hundred dollars(5500).
p 1,as owner of the pmpeny,or my employees with wag"as their rete compensation,
will do Newark and the mructme is not intartdad or offered for sale(Sec.90aa,Business
and Pnocanio"Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds orimpmme thereon.and whodoessuch work himself ortam ugh his
awn employees,provided that such improvements arc not intended or offered retrain.IL
however,the building or improvement is mid within one year of complcuon,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owner of On progeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7014.Business and Profusions Code:)The Cunuenteri Li
me Law docs not apply to an owner of property who builds or improves themun,and
who contracts for such projects with a eonvmmr(s)licensed pursuant to the Contractor's
License law.
❑1 am exempt nder See. B&P C for this region
1wral DatWORKERS COMPENSATION DECLARATION
1 hereby aRrm under pcugly of perjury ane of the following dectu ations1 have and will maintain a Cen heat.of Consent m s lf-inage for WorkciaCompcn-
ion,u provided for by Section 3]00 of Ne labor Code.for do pe forreana of IWrk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of the La W,Cade,for Ne performance of Ne work for which this permit is issued.
y Workers Compeanst Insurart¢easier and Policy number ammar. /ak�'p V'ss^M• Policy No.: t—`f 3 4 5 '1_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for onchundred dolls(SIM)
or less.) ,
1 unify that in On perrotmmum of the work for which this permit is issued.I shall not
employ any person in any manner m as to Wcomc subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to the Worker's Compensation provisions of the labor Code,you most
.JO forthwith comply with such previsions or this permit shall W deemed mvokcd.
'z CONSTRUCTION LENDING AGENCY
{— 1 W reby aRnn that there is a construction lending agency for the performance of
C(i the work for which this farm it is issued(S.c.3099.Civ.C.)
dQ Lender's Name
=z Lender's Address
U Q 1 comfy that 1 have read this application and sure that the s Wve information is
U,F conga.1 agree to comply with all city and county ordinances and state laws relating to
0U building commotion.and hereby mthorim mfrcsenuriaes of Nis city to enter upon the
Y'a aWvo-mentimad progeny for inspection purposes.
(We)agree to save,indemnify and keep hmpless the City or Cupcnino against
TA Iiebilities,judgmcnts,eosts and expenses which may in any way secmc against said City
U in connote, of the granting of this permit.
^ APPLICA NDER N d/p.�D WILLOMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULA S./ �C '_ ' _
5/) e S Re-roofs
Signature of ApplicaDate
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle harvdous material
a dcfmcd by Oc Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
. 0 Yea eazss3z(a)? IANO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rutum building occupant esu equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air contaminants as dcOncd by the Bay Area Air Quality Management all new materials for inspection.
Disoict?
❑Ycs akal�
1 have mad!rhe haramous materials requiroments unaler Chapter6.95 Oldie Califor-
niaHealth&Safely Code.Sceuons25505,25533uu12553d.lunkmwdthatirtM Wilding
doea not currently hast a tenant Out it is my responsibility to nouly the Occupant of the J
roquiremenZ mug Wmetpdpr iamftec r CmfflCmrafGcCo y. Signature ofApplica t Date
te O All roof coverings to be Class"B" or better
Owner Date
Community Development
10300 Torre Avenue
s' Cupertino CA 95014
Telephone(408) 777-3228
� CITY OF Fax(408) 777-3333
UPEI�TINO
Building De artment
JOB ADDRESS: yPERM�IT
Soo 9 _y #
OWNER'S NAME: PHONE # y 9-733 z-
GENERAL CONTRACTOR: OlFAX #
I am not using any subcontractors: Codi. _ i�— - / 710--s
Signa re 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
Tire ��a�
7/o S
Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
CITY OF Telephone: (408)777-3228
OU P E IST 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.
e 5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
r 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: 41
Job Site Address: 7�
Roofing Company Name: ,21O/
Applicant's Signature: Date: -5 / 7/0-5
Greg Casteel
Building Official
Revised 11/2/04
Printed on Recycled Paper
CITY OF CUPERTINOaa�v
q
REROOFtFTTdF
CUPERTINO PERMIT APPLICATION FORM
APN # 3 6 R _ 2 d - U 3 1 Date:
Building Address:G yqs—+ G ,1,4 7 J
Owner's Name: Phone#:
3 -2-
Contractor:
Contra��� Phone #: 7 License 4: 7 ,3
2-x'300 22
Contact: Phone#: S _ Cupertino Business License#:
..vim
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
'g 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: T/p ' 4 -5--c,y.,)
Residential ilk " Commercial ❑ �� Y
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions: LJ
Cost of Project: o,0 Type of Construction: Occupancy group:
/O DW
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
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