R-5672Il
a
OFFICE COPY
PERMIT
R- 5 6 7 Z
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
2 2, L 2, cL
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
L
YES ❑ If as — I understand that a Class A
r,l
NAME T✓ I✓(
rppf assembly is required.
NO ❑ Ini, I.C.B.O. x
Z�-/Z�2- Y3� ��.
EXISTING ROOF COVERING
ADDRESS
'— J
NUMBER OF EXISTING COVERINGS I
PHONE y
CONTRACTOR'S'
TO BE REMOVED TO BE RETAINED
NAME �uI tnVy, I� Pte- tAru—
r
La
TYPE OF ROOF COVERIN
CITY & Z P ~r 1/� ��t�� s
EXISTING
f 017 3 3
//
�" ��/C
PHONE 77
❑
BUILT-UP ROOFLICENSE
NUMBER ZOJ /
ASPHALTSHINGLES ❑ 7/
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7001 0)of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
License Class Lic. Number -
WOOD SHINGLES ❑
OTHER (SPECIFY) ID
Date Contractor
OWNER -BUILDER DECLARATION
PAID
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter. Improve, demolish, or repair any structure, prior to its Issuance, also requires the
BUILT-UP ROOF 5 00
-��ff nl$
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
01 the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
Any Section 7031.5 by for icant to
ASPHALT SHINGLES uL` ��'
exemption. violation of any applicant a permit subjects the appl
a civil penalty of not more than live hundred dollars ($500),):
do
�rN (✓UIILiPi'I�INO
WOOD SHAKES 'I 1
❑
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Profes.
slons Code: The Contractor's License Law does net apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
WOOD SHINGLES El �� 6WttO
Is aoto within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) V1 W
not build or Improve for purpose of sale.).
O I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (sec. 7044, Business and Professions Code: The Contractors License taw does not
PROVIDE I.C.B.O. REPORT NO.
apply to an Owner 01 property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Lew.
PROVIDE MFG R. INSTALLATION SPECS.
Q 1 am exempt under Sec. ,B & P. C, for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
/ /
�(�� CYC
Building/�
/W
I hereby affirm under penalty of perjury one 01 the following declaration:
❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
t
provided for by Section 3]OO of the Labor Code, tenths performance of the work for this
2
permit is issued.
have and will as
Worker's Compensation Insurance, as required by of
d byS
Iain Woance
(/
$eISn11C
I bon Cade, for the req Is My Worker's
the of the work for which thea Issued. Mya orke
the workfor
7 Compensation Ijrm'urence rarrtm a�ntl/Policy number are:
Total
Carrier �--L1c�b Policy No. KBO :7:3
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
G
I certify that in the performance of the work for which this permit Is Issued. I shall not employ
any person In any manner so as to become subject to the Workers' Compensatlon Laws of Cell-
All roofs 5 be inspected prior to any roofing material be' g
forma.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
I. i. OWorkers' compefnsation alter makingos Certificate of become
you
Applicant understands and will comply with all non point
subject the s of the Labor Code, moatufa thwliit
th comply
with such provisions or this permit shale be deemed revoked.
ns. -
SouAAE'
I certify that I have read this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All s 10 ass "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
-
spection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costa and expenses which may in any way accrue against said Clry In consequence
SIGPPL DATE
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
ASP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
E
0
TIF CITY OF CUPERTiNO BUILDDiG DEPARTi 1Ftii
SUBJECT: REROOFRNG POLICY FOR e er ION pv �cE
PRIOR TO ISSUANCE OF PER.NII T 'kND N+ SPEC
1. Prior to pe^r it issuance, you must a; e-_ to comoiv with U.B.C. standards and rnanufacry:e:s sec's
on re:conng.
2. New roof coverings shall not be atiolied without first obtaining all in pecdon and vvrinen aceroval
from the building irspr_ror. A final
ince non and approval shall be obtained from the building
inspector when the reroofing is camoleted.
3. All types of roof shall be inspe•_':ed prior to any roof being installed.
4. In order to receive a final, you Mu
n complete steps 1, 2, and 3.
1)--P-
�i narC^�Dn9LrLf-Off'aBCitSYsl.. l'
2.) In progress in--pec-don approval.
3.) Final inspection approval.
a.) Operable smoke de,. --.or verincaden
b.) Spark arraror installation
5. If plyvveed is installed, a Plvwccd nail lase=tion is required
6. If any roof is applied vvithout firs: obtaining an it s e tion You vvill be require3 to remove all ne v
matenal down to the sheathing and a building in_�e= or vvu in pec all sheathing at that time.
E UNDERSTAIND THE ABOVE POLICY ON REROOFING"—"D WILL COMPLY WIT'r
WI TziE
POLICY
EO,AEOWWERS NAME:
ADDRESS:
REROOF u IG COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerooflwimvdrd
e