03070122 CITY OF CUPERTINO '�°' *�° � *k +*
BUanINc DIVISION PERMIT CONTRACTOR INFORM°ATION '
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BUILDING ADDRESS: OLD COUNTRY ROOFING PERMIT N003070122
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OWNERS NAME: 125-B GROBRIC CT �`�"T`�"EDA78
NE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: � n BUILDING PERMIT INFOn ,BO ELECT PLUMB MECH
O O
aoo LICENSED CONTRACTOR'S DECLARATION ••T '�
F I hereby orrirm that I em licensed under provisions of Chapter 9(cnmmcncing Job Des tion
n
With Section]IXNglirDivision 3o(theBusiness radProfessin aCnde.mdcn
myliecle i6 1 2 03
in ran force and effa /���.:+.I C
Sq?
I. m Lic.N V REROOF
n Da¢ Cuntrsemr C- U 11�� `
ARCHITECTS DECLARAT N B�u���lgg,�
�i l understand my plans shall he used u public records gV
oil
3 Licensed Professional
^
OWNER-BUILDER DECLARATION
41 hereby affirm that I am exempt from Ne Contractor',License Law for the
t eO following memo.(Section 703 1.5,Busimat and Prressinr Code:Any city or county
o which requires a Permit an consumer.alser,improve,dcmnlieth,lir repair my atrclum
prior o in issumce,,ho requires the mplicam for such Permit to rile a signed statement
000
that he is licensed punuanun the provisions of to Contractor',License Law(Chapter 9 Sq.Ft. Floor Area Valuation
Fz❑O (commencing with Section II000)of Division 3 of the Business and Professions Code)or
3
that he Is eaempt therefrom and Ne breexemption.Any vinlniois for the alleged n of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of APN Number Occupancy Type
not mom On five hundred Median(S500).
❑1,as owner of the property,r my employees wit wages as their sale ministration,
will do the work and them,am.is not intended oroaemd foutle(Sec.7044,Business - 305 - FRAME .
and Professions Code:The Contactors License Law docs not apply m an owner of Re mired Inspections
proPeny who builds or improves thereon,and who doeasuch work himselfor through his 307 - INSULATION
own employees,provided that such improvements sat not Intended ara0ered forsale.If. 601 - ROOF TEAR OFF
however,the building or improvement Is sold within arc you orcompletion.Ne mmen
Wilder will now the burden of proving that he did r.1 build or improve for puryose of 602 - ROOF PLYWOOD NAIL
"l`')' 603 , - ROOF BATTENS
❑Las awmr of project
property,,Business exclusively confessions with:)Theed eomnmort m
cameLa Metnom(Sec.7044,wnantl professionsCode:)or i Thwe;Mercer,Li 604 - ROOF IN-PROGRESS
core dew docs not apply to ts Dinar of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant in dm Contractor's
License dew.
❑1 am eaempt under Sec. .B&P C for Nb ream
Owner Dm
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the following decimations:
46 1 have and will maintain•canirimmor Consent m sel6imum for Worker',Camper.
saloon,as provided for by Section 37W of the Labor Code,for the performame of Ne
work for which this permit is issued.
�IWhave and will maintain Workei,Compensation Insurance.as required by Section
of Ne Iebor Code,for Ne performance of Ne work for which this permit is Issued.
My Wmkc's Compensation Insurance carrier and Policy number am: .y
Canie /M -L UNI Ow IHS Policy No.: M/G.SI ji 2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseetioe need not be oomplemd if the Permit is for one hundred dollars($10,14
It..)
I cenify MIL in the perfmorum.of the work for which this permit is issued,I shall not
employ any person in any manner an As to become subject to the Workers'Compsmatlon
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption,you should
become subject to Ne Worker.Compensation provisions of the Labor Code,you mus _
OZ forthwith comply with such Provisions or this permit shall he deemed revoked.
,ZO CONSTRUCTION LENDING AGENCY
.F I hereby affirm Nal there is a construction lending agency for Ne performance of
7.> the work for which this permit is issued(See.3037,Civ.CA
QLender's Name
z Lender's Address
U I terrify that I have read this application and scale that Ne above infoorulun is
14 correct.I agree to comply with all city and county ordinances and sune laws relating to
0O building constme ion,and hereby awhorine represenulivcs of Nis city to enter upon the
W ahavomentiuned property for inmemion purposes.
Q. (We)agree 10 ra ,indemnify and keep harmless N Ci of Cup,vino against
Ny IlabiliticsJudgmcntacosts and expenses which may in any way accrue against saidCity
O Z in co recd wace of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
souac uf�
;A'�IONS.-, 2,t6r7� Re-roofs
Signature of Applli�cctunfiCunummr Data A
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Wcupml ume or handle ha Dun,material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Coca,SKIM as3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
�_k-
❑Yes
Win the applicant or future building occupant use equipmem or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
it hmardnua air cmiu ninants as dermad by the Bay Area Air Quality Management all new materials for inspection.
Islrlcl?
❑Yet
I have mad the hnvardous materials requirements under Chopur6.95 of the Califon �/ ^��
nia Health&SafelyCodc,Sections25505,35533 md25534,1 understand Not ifthe building /�,
does not curmndy how a tomo,Met It is my responsibility to unity Ne occopanl of the
requirement wIt h must be mel prior i issuance are Ccniricale rasp er. Signature ofApplicant Date
�� ; f��D? All roof coverings to be Class "B" or better
Owner or authmimd agent -Ilam
Building Division '
10300 Tom Avenue
CITertino,CA 95014-3255
` Telephone: (408)777-3228
CUP
Pax: (408)777-3333
EI�TINO
Building Deparitment
Subject: Reroofing policy for the City of Cupertino.
,
L. Trior 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 fust 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**+i*++**+um of YL"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: __� U'f''l e�) �
Address: 0�`�O PAIl /-1oN-1 /0�l C-t7
Peroofing Company Name: (24-5-� CguN �i CZoO� G
Applicants Signature: / Date: S-' CL
Joe Antonucci
(Chief Building Official)
6/25/01
CITY OF CUPERTINO
REROOF d 3 " 7 "/ z Z
CUPEkTiNO PERMIT APPLICATION FORM
APN# o7a Q Date: / S l oa
Building Address:
0a4o iso
Owner's Name: Ph #a � 3 // 2
U m PIA) ��� Lf o
Contractor: Phone#: ° tense #:
�26., COoA,t , 00't(L)6 F'300 71,3
Contact: Phone #: Cupertino Business License#:
/-cam pOoo 03
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes Cl Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) Other(Specify) MOA))
Number of existing coverings Provide I.C.B.O.Report#
Cl To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Com 1 With Cu ertino's Tear Off Policy:
Job Description: C-M0✓; AXIS i la S in _s Tl/"—t- C> .as
60 4- 04( elk . 4-1 .mss,-
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there frictions: LJ
Cost of Project: Type of Const tion: Oc pancy gro
Loo0 Oof 3
Qtyff
A lic ble Fee ID Fee Descri tion 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
Sin
gas