R 5099 PERMIT R_ 5 0 9 9
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
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WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
(Q& 2 //[/
er / FIESIDENTIAL-7k COMMERCIAL OTHER
wNE HAZARDOUS FIRE AREA
NAME Q r v1 I YES ❑ If yes–I understand that a Class A
NO Croof assembly'Sq.
Initial I.C.B.O.If
ADDRESS Q EXISTING ROOF COVERING
PHONE — /U / NUMBER OF EXISTING COVERINGS
CONTRACTOR
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CONTRACTOR O a /J/N n
NAME�(J S //����C.-��_S , ` –/f- Y TO BE REMOVED TO BE RETAINED
ADDRESS P771 /.� _ / 17�7 / J— TYPE OF ROOF COVERING
CITY&ZIP ((�Y //,.L� / L So 3 EXISTING
PHONE S `c ?G'S I �� G/ / BUILT-UP ROOF ❑
LICENSE
NUMBER 3s�'l ZJ ASPHALTSHINGLES ❑
LICENSED CONTRACTOR DECLARATION -
s I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Profession e Cad m Ilgppse Is i to force and
effect. K/ WOOD SHINGLES
License Class Uc.Number OTHER(SPECIFY)
Data 2 — Contractor 14
5C
'
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Bu that am exempt from the Contractor's License Lew for the following reason.
(Sec.7ct,alt ,improve and Professions or rep it any Any city or county which requires a permit to
construapplicntfor alter,Improve,demoto file signed statement
thate,prior tolls)pursuantelstheprovisthe BUILT-UP ROOF ❑
of the
for such permit a file a signed r 9(comm that g with
Sectio pursuant to the provisions the
• of the ss and tPre Licence Lew(Chapter 9(commencing with Section 7000)of for the 3 of the
exemption,
entl violation of Coda)or that he is exempt therefrom and the beats for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by enys($5 for a permit subjects the applicant to
e civil penalty of not more than Ilue hundred dollars($500)0t):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles.
dons Code:The Contractor's License Law does not apply to an owner of property who bullds or WOOD SHINGLES
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
is sold within one year of completion,the ownef-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contmcgng with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects yr
with a c m exempt
ulicensedSe pursuant to the Convectors License Law. PROVIDE MFGR. INSTALLATION SPECS.��.
ED I em exempt under Sec. ,B 8 P,C.for rale reason
OwnerData
WORKER'S COMPENSATION DECLARATION APPLIC I N DATE VALUATION PERMIT FEE
TIO
I hereby avlrm under penalty of perjury one of the following declaration: .410
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued.
01 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of t 20 1998f
.S �O�I f�� Seismic
_the Labor Code for th peterrlta1, of the work for which this permit is iaauad.My Workers Uy- s
r Compeneetlo dsuran a carr end Policy number are: Total
Carrier I Pc1lcyNo. L06 I1SS PERMItAOtHORIZATIO DATE
R I
CEFICATE OF %EMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shll not employ
MI)
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fofnia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject to
tBthe Workers'Compensation provlTO APPLICANT: It,after ilonle of the lLabor Code,cate of you must forthwith ou lbcmply Applicant understands and will comply with all non point
with such provisions or this permit shelf be deemed revoked. source regulations.
I certify that I have mad 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 roof coyaungs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
epectlon purposes.
g(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, ��jl� 12-19--f6
• oftlhe granmemt-ting of tand his perrmll es which may in anyway accrue against said Clry In canaaquence SI T( URE O�PLICA DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP, DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all in rection 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 types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1, 2,and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed, a plywood trail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME: —1,t- CQl�Gt' v `09A-J _
ADDRESS:. . 2 O (o 2 C,H
REROOFING COMPANY NANM: S G'A fv s /MJF/ G
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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