03120123 CI"I'Y OF CUPER'fINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUII.DING ADDRESS: OLD COUNTRY ROOFING PERMIT NO03120123
01C)" FLORA VISTA A17R —
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
(707) 864-5997
ARCHITECryENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECII
(� (�
�Oo LICENSED CONTRACTOR'S DECLARATION
❑ I hereby affirm That 1 am liwnwd mode[you kions of Charm,9(commencing J e;cription
iW wifSection lo)))afDwixionJoftheBusinessand Professions Coca.aMmyliecnuis ll��//!{{
^gid m rmu•My.�•,ndarfaaL /(t .3 REROOF •fir ���
n> ucansr a ' Lim.x
l-as Da¢\\'' ARCHITECT' IncCLAOr RATION 0 „2 1 5
�66d eland my plsea a hall he used as public mroNs MAR 2004
>yU
3 0 Licensed Professional 1� g p�
g OWNER-BUILDER DECLARATION 13 pX�RLn
Y 1 hereby affirm Ilial 1 am exempt from the Contractor's License Law fur the �Y OtivJ
00 following reason.(Section 7131.5,Business and Professions Code:Any chy or county
K m which men ims a permit to construct,alir impm.a,demolish.or repair any structure
y¢iprior o its issuance.also myures the applicant ror such permit to file a signed statement
athat he is licensed pursuant 4)the provisions of the ComrutorsLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
y_0 (commencing with Section 71X)0)of Division 3 of lbs Business and Professions Com)or
i 3 S that he is exempt Therefrom and Ne basis for me alleged exemption.Any violation of �s,nw�.wn�w.x
Section 7031.5 by airyappliaanl for apermit subjects Inc applicant to a civil penalty of 36"OV8V2LgrO0 Occupancy Type
not mora Nan for,hundred della.($300). ..
❑L as Owner of the propony,or my employees with wages As their salt compensation,
will do Or work and the•vudure is not intended or offered for sal[(Sec.7046.Business
and Professions Code:The Contractors License Law does not apply W an owner of Required Inspections
property who builds or improves,Neeson,and who docs such work h readfor d rough his
own employees,provided Oat such improvements arc not intended or offend for sale.If,
however,me building or improvement is sold within one year of completion.Oe owncr-
builder will have Inc burden of proving Oat he did not build or improve for proposer of
sale.).
❑I.as owner of an papeny,am exclusively connecting with licensed contractors to
construct the project(Sec 71146.Business and Profusions CodcJ The Comrazmri Li
camor law cars not appy to an owner of proNny who Ni Ids or improves menton,and
who contracts for such pmjccu with a contractions)licensed pursuant re the C maracter's
License law.
❑1 am exempt under Sec. B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby Affirm under Penally of perjury arc of he following declarations:
1 have and will maintain a Cerffaam of Consent to self-insure for Worker a Comp[n-
As ion,as provided for by Section 7700 of me labor Code,for me performance of IW
work ror which this prom it is armad.
1 have and will maintain Worker's Compensation Insurance.u thrumed by Section
of are Labor Code,for me perfmmance of me work for which this p[mat is issued
My Worker's Compensation lnsuena camq�Policy rr�mncr art:
Tr�AT/OAjfhL Uri/dl�Via$ ,
V c' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mi.section need not Ne completed if the permit is foron[hundred dollars(SIDE)
in less)
1 mnify Our in the p[rfnmism.of me work for which this pearl,is issued,1 shall Out
employ any person in any manner an u O become subject to the Workers''Compansation
Lava of Califumia.Date
Applicant _
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
become subject to the Worker's Compensation provisions of the Lear Code,you mut
.JO forhwith comply with such provisions,or his room,start W damcd revoked.
Z ^ CONSTRUCTION LENDING AGENCY
I mphy affirm mat mem is a construction lending agency for mclerfumance of
C me work fur which this Iearth is issued(Sec.3097,Civ.C.)
[t7 Q Iend[rs Name
,z lender's Agrees V
O Q 1 certify man 1 have read aria application and item that me above information is
0 Wilda.1 ager m comply wire alt city and county oNtives of and sum Iowa r upon t e
�O aboyWilde-gartumed construction,And hereby aahon prposescnutircs of ariacirymcnrerupon the
C enovc(We) gee pmpcny for int tify An purposes.
(Ws,)agree to rase,indemnify and keep M1art in an the City of against against
Iiacoisequnce of . six and cf mr,per I. may in anyway accost against said City
f)z A APPLE
ANT of c erring of Nis per I. (/
^ APPLI ANT D RSTANDS AN IL- LY ITH ALL NON-PO Issued by: Date
50 ERE TIONS'"`
1 '� Re-roofs
signature of pphcanJContrazmr D c
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill me applicant or future Wilding occupant store or handle hazardous material
as mad
by the Crimp,no Municipal Code.Chapter 9.12,and the Hcalm and Safety
ale.OSecYo[an255J2(a)? o All roofs shall be inspected prior to any roofing material being installed.
Will Inc applicant fumm Wildingoccupanntaucyuipmenterdevireswhich If a roof is installed without first obtaining an inspection,I agree to remove
it m ardour air conumrean u defined by the Day Arca Air Quality Management all new mater s for inspecti ❑.
iriamt? /L5
❑Yes X Nu
I have mad Oe haaar/douussmalarials rtyuimmenu under Chapter6.95 of the Califor-
ro.HralthB tyCMc,Sawas )5, l an 25514.1 undc.nmd mmiflnc Wilding
dins not c Oy hart a tan til' siM1' yIo notify nbc acupanl f Oc _(l�J GY
myuiOr_n -hien mea _ as of n; aameraa anry. Ig tore of Applicant /. Date
aamornea agent
%,mZf All roof coverings to be Class"B" or better
Community Development Department
Building Division
'y City of Cupertino
Y10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
UPEkTINO
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.
l 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: —L I I IL)(2
Job Site Address: `J 9 L7 ✓"L O 4 �c
Roofing Company Name: 0 L/�Q �C�Q /f/t1TOf'
A plicant's Signaturh� / W Date: 3
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
CITY OF CUPERTINO
awn REROOFCITY OF
o 3 z z 3
CUPERTINO PERMIT APPLICATION FORM
APN# 2 (f) Date:
Q C 0
Building Address:
(Old q 6- 'LO/Z v/,y7-?-{- �(✓
Owner's Name: I Phone#:
ro
Contractor: Phone#: 7 cense#:
oL� co (4 ntrrZ_ (Z,00i-, jo b'a F'300 ( 3
Coaact: Phone#: Y ,0 J14, Cupertino Business License#:
b'c3 0 0 RO
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
A 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: i Nl VV C X I Z3 —/�O V
N sTn-L_� 3 0 yA_
Residential 0 Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De
there are any restrictions:
Cost of Project: Type of Construction: Occupancy group:
l O 00
Qty. if
A 'c ble 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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