03070123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION -
BU ILDINGADDRESS: OLD COUNTRY ROOFING PERM1TN003070123
OWNSwy
' NAME: 125—B GROBRIC CT pERMITIS SDE DATE
ONE: (707) 864-5557 SANITARY NO. CONTROL NO.
ARCHITEC ICNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
i?OQ LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby erfmo Ihel 1 am licensed under previsions of Chapter 9(commencing
U wide section]fl ))or Division 3 ar We Busincuend Pod...inns Code,end my license is
in full tone vnd crfcc
jg? License l.s Lic.s o�'d�31 REROOF
L—p Dau a Contractor _VU AI'Cnn!q
rt�t� ARC HI'IECTSDECLARATION
owes
1 understand my plans shall headed u puhlic records J U L 2 9 2003
G Licensed Fore.l...I
3s. OWNER-BUILDER DECLARATION
'�<Y 1 hereby vlfirm that I em exempt from the Cnnuecmr's License Law for the BUILDING
a O rollowing reason.(Section 703 1.5,Business and professions Code:Any city or county
x m which requires a permit to construct,alter,improve.demolish,or repair any structure nnn
prior to its lssoance,also requires the applicant for such permit to file asigncd statement
m< that he is hccnud fondant to the provisions of the Commuters Liecraw Law(Chapter 9 Sq.Ft. Floor Area Valuation
yF (commencing with Section 7")of Division 3 nrihe Business and Professions Cafe)or
k'W$E that he Is exempt therefrom and the basis far Ne alleged exemption.Any violation of c;9,onr4 10
Section 7031.5 by any applicant for.permit subjects the applicant lo.civil pen.ey of APN NumberOccupancy Type
not more than rive hundred dollars(5500).
I,.mvncr of me Pmpeny,or my employees with wegnudeelr sole compenutlon,
will do Ne work.and the structure is not intended or Offered for safe(Sec.IDN,Business 305 — FRAME
and Professions Colic:The Contractor's License Law does not apply to an owner of Required Inspections .
Property who builds or improves themon,and whodmssueh work himulforthrough his 307 - INSULATION
own employces.provided that such improvements art not intended or offered for sale.If. 601 — ROOF TEAR OFF
however,the building or improvement is sold within one year of completion,the Owner.
builder will haw the burden of proving that he did not build or improve for purpose of 602 - ROOF PLYWOOD NAIL
603 - ROOF BATTENS
I,.Owner titheproperty,am.Business
commons with
,,.. alhue.Outtpplya.t3nmine nossand Professions.Or:)Than.the....Li. 604 - ROOF IN-PROGRESS
ecnu Law lima not apply e an owner of property who builds Or improves thereon,.d
whence Law,for such projccu with a emtncmr(q licensed pursuant to the Comnnor's .
Lic
❑lam exempt under See ,B&PCfor this..an
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby effrrn under penalty of perjury one or the following declarations:
1 have and will maintain a Cenificau of Continuo ulFinsute for Worker)Compere
.tion,u provided for by Section 3700 of dee Labor Code,far the performance of the
rk for which this permit is issued.
I have and will..least.Worker,Compensation In.....as required by Section
37 of the Labor Cade,for the performance of the work for which Nis pemtit is Issued.
My Worker'.Compensation Insurance carrier Policy nu hernre:
C.rtier��I'fyL (.I.UIaA7 /IlV polity No: 16�aa
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tris suction need nut becompleted if the permit is for one hundmddnllars(SIM)
nr leas.)
1 certify dent in the performance of the work for which this Permit Is issued,l shah not
employ any person in any manner so as rtt become subject to the Workers'Cntnpen.ation
Laws of Celiromik Dau s
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption•you should
become subject to the Worker's Compensation Provisions Of the 1ahnr Code,you must
.JO forthwith comply with such provisions or this permit sh.11 be deemed mvokcd.
, CONSTRUCTION LENDING AGENCY
's-s lherehy Orion that then is comtmctinn lending agency for the pafurmance or
cd 7 den work fur which this permit is issued(See.3097.Co.C.)
0 Under Name
z 1<nder's Addre.s
O Q I certify that 1 have read this application and sou that the above information is
tL P correct.l agree to comply with all city and county ordinances and state laws relating to
O U building etnswclicto and hereby stadmise representatives nrthis city to com,alum the
Galmm-mentioned property for inspection purposes.
(Wa)agree to save,indemnity and keep harmless the City of Cupertino against -
,F.t fn liabilities,judgments,costa and expenses which may In any way accrue against said City
U Z APP ` I the mming of Ipermit.
LICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REg �oN�' ---�
-+ �j 6- Ck5 Re-roofs
Signature of Applicata Contncmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle harsrduus material
as defined by the Cupertino Mynicipal Code,Chapter 9.12,and the Heald and Safety
Code.Section 35532p)7 tet/ y, All roofs shall be inspected prior to any roofing material being installed.
go ❑Yes
wee dee.pphr.ntar m anwilding«salons a egalpmem ardevi m which If a roof is installed without first obtaining an inspection,I agree to remove
tit hv.rdnas air cnn'numants u defined by the Bay Area Air Quality Management all new materials for inspection.
iur e'?
0 Yc.
Ih&Safetl thc Cut..Srdnu ,25505,rc33and requirements Chapter 6.95 of the bariumn �� 1� / / —� is r/6' D�
noel{ca I have..Iy Colic,Sccdnns 2550als req land rats on-1 rCha tard that r6.95 fthe building
sues not curtently hero a tenant,that it is my resgmdhilily to noti ly the occupant of the
mquimmcn whicl ps,nM ret ormisaaeneeer a cenm.te or occupancy. Signature of Applicant Date
/ j� -16- os
All roof coverings to be Class "B" or better
Owner unmhori'rod eget[ Date
t
Community Development Department
aAM-e Building Division
City of Cupertino
10300 Torre Avenue
. Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
CUPS TING
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 Y4" 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: LL%K cc(-�ZN rc�
Job Site Address:
Roofing Company Name: 'yG
Al2plicanfs Signature / Date: -7 7 5" 03
Greg teel
Building Official
Revised 1/30/03
Printed an Recycled Paper _
CITY OF CUPERTINO
REROOF
CUPEkTINO PERMIT APPLICATION FORM
APN# 36 9 3__� Date: f
BuildiAddress; 7
i toga ' w 6_s way
Owner's Name: Phone
Contractor: Phone#: t f Od'• License#:
04. 2,Ea F300 �� "33 /
Contact: Phone#: Cupertino Business License#:
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
A Other(Specify)C<`f-, I LAX— ❑ 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: r2�%t�'t Ov or L tcSTr �/ e Lr�C NT Nr?Yc. r�ti os3
3 e Vt 4- (fc=2 i/tt n/-1 6!Z) 60 A Com,
Residential Commercial ❑
ire Zone: Yes ❑ No ❑ Confirmed wi De t. if
there are restrictions:
Cost of Project: Type of Construction: Oce ncy group:
w / Oo0 %�oo�= - 3
. t
APO' aW Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
lef BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
7'