R 5949 `
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 5949
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT- (418)]]]-.9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /y/
re e om RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//•fes ,. r/1 VES ❑ If yes—I understand that a Class A
NAME eAA1NQ4 C' O � C./GC`9.dC2!��/IV roof assembly is required.
x NO ❑ Initial I.C.B.O.N
ADDRESS 77 yso3 EXISTING RO
`?(10
} OF COVERING
PHONE 495` 0/ / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME—
/ /
6
L-o S S O h TO BE REMOVED TO BE RETAINED
9
ADDRESS C�. R_ /�7 / /' /S /�e?�EXISTING TYPE OF ROOF COVERING
CITU 8 ZIP—/s 4- /�� (�C/ (JZt,raj .J _
PHONE_ 7 V, �S� BUILT-UP ROOFLICENSE
❑
NUMBER Y ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 6(commencing with Section WOOD SHAKES
7000)of Division 3 of!t BQsi�ess and Professions Code,and my li2enssee.l/I/full force and
anon -��_� WOOD SHINGLES 8 License Class Llc.Number
Dale Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions P
to
of the Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 of the I<-
Business and Professions Code)or that he Is exempt Therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred tlollare($500).): p r
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES JUL MNSD
the work,and the structure Is not Intended or offered for cele(Sec.7044,Business and Proles.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES f
Improves thereon,and who does such work himself or through his own employees,provided that Vil}
!f y)r ❑+ +—.. ....
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulld or Improve for purpose of sale.).
❑I,as owner of the property,em exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does 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 f(
with acomexempt licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,8 6 P.C.for ihl9 reason
Owner Dam
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 31r
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, BUlldln
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which the 7�Z-�� Building
(311
Is Issued, (o O
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of (�/QO SelSR11C
-the Labor Cod ,for the pertormance of the work for which this permit Is Issued.My Worker's !(
Compensalio Insurancecarrier an oil - are: �f��O Total r Q
Carriervt Policy N PERMIT AUTHORIZATION DATE
CERT FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.p
(Thie section need not be completed If the permit Is for one hundred dollars($100)or lees.) T r O —2——'F D
I certify that In the performance of the work for which this permit is Issued,I shell not employ 1 0
any person In any manner co as to become subject to the Workers'Compenaapon Laws of Cali. All roofs shall be inspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shalQbe deemed revoked. source regulations.
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 roof coyxings to be class"O"Of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes /
(We)agree to save,indemnity and keep harmless the City of Cupertino eaainel liabilities, �' ��` z���
judgment., ..'a
and expenses which may in anyway accrue against said City In consequence
of the pro 'Ing of this permit. SIGkATQRE OF APPLIC/EAT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
CITY OF CUPERTINO - BUILDING DEPARTMENT
• RE-ROOFING POLICY
1. Prior to per issuance. you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections 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 types of roofs 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. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final.inspection approval
a. Operable smoke detector verification
5. If plywood is installed, a plywood nail 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 sheating and a building inspector will inspect all sheating at
that time.
IVi IPORTAtNT:
1. Flat roofs must have a '/4" per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE.POLICY. //O�
HOMEOWNER'S NAINIE: ln(�1�1(2ll)//1,5
ADDRESS: l c/ -7
RE-ROOFING COMPNAY NAME: (-as
APPLICANT'S SIGNATURE.
CITY OF CUPERTINO
• BUILDING DEPARTMENT
Rrrnor/winward