R 5944 PERMIT R_ 594
4 .
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40 7 -3228 PERMIT EXPIRES IF WORK IS NOT STARTED
�f WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 Be DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
XD0RESIDENTIAL COMMERCIAL OTHER
Gw R' n /J HAZARDOUS FIRE AREA
�.� YES ❑ It yeas I assembly
is
that. Class A
NAME roof assembly is required.
NO Initial I.C.B.O.W
ADDRESS a/ r q�/ `7" //PYS/7L 1-6-112.5030EXISTING ROOF COVERING
PHONE _ 24,076 "7� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�QS US ��� �/�� TO BE REMOVED TO BE RETAINED
NAME /' �" `
ADDRESS �G1' TYPE OF ROOF COVERING
CITY azip EXISTING
PHONE �.,,Z>� 233 BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED
underCONTRACTORS DECLARATION
hereby iaffirmnion that I em licensed under Professions
of Chapter B license clop with Section WOOD SHAKES /'p—'�•.
7000)of Division 3 the Business and Proleselene Cotle, my license I fi Lill force and effect
License Clea. Lic.Number WOOD SHINGLES
Gate Contractor
OTHER(SPECIFY)
OW from BUILDER DECLARATION K2
PROPOSED
hereby elllrm that em exempt from the Contractors License Lew forme following permit
to Z
(Sec.7ct,alt Business and demolish,
or rep Coda: Any city or county which requires a permit to d`� - /
conrruct,alter,Improve,tofile a signed statement
prior topeissuance,uant alsorequlree the BUILT-UP ROOF eyL .
applicant for such permit to file a sipnetl statement that he Is licensed pursuer to the provisions <Clp
. of the Contractors License Lew(Chapter 9(commencinp with Section 7000)of Division 3 of the
Business and violation
Code)or that he Is exempt therefrom and the bene for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of than
five 7031 hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than flue huntlretl dollen($500).):
❑I,as owner of theproperty,or my employees with wages as their sola compensation,will do WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles-
' alone Code:The Contractors License Lew does not apply to an owner of property who builds 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.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑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 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 h A.
with a aonve )licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exemptemptunder Sec. ,B 8 P.C.for This reason .0401.
Owner ore APPLICATION DATE VALUATION PERMIT EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certlflcate of Consent to sell-Insure for Worker's Compensation, � ' Bulldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. $@
❑ neve and will the pert Workrmanc9s pf the work
for Insurance,as required by Section 3700 of _ QQ MAI-
the Labor Code,for the performanc 1 the work for which This permit Is laeued,My Worker's Il 1pp 23 Total
Compenea,l nlneurance carrlera otic t m ere: WH/V Ib
Cerrle policyRM-11.AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ _
(This section need not be completed if the permit Is for one huntlretl dollars($100)or less.)
I cenlly that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner sur as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be nspected prior to any roofing mail being
forma. installed. If a roof Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject 2 the Workers'CompeE TO APPLICANT&. lnsrion provisions of thellcate of Laborr Code, mustufo forthwithshould
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that l have read this application and State that the above Information Is correct.l agree cove m comrebs ly authorize
all city and se county of this cea and ter u on relating to above-mentioned
d property
and All.roof covL2 eyegg to be Class°O°Or better.
hereby authorize representetivae of tole city to enter upon the above-mentioned property br In. '
epectlon purposes. p
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
• judgments,coats and expenses which may in any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPL CA 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
CITY OF CUPERTINO - BUILDING DEPARTMENT
RE-ROOFING POLICY
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
r
New roof coverings shall not be applied without first obtaining all inspec;ions 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.
_. 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.
LNi IPORTANT:
1. Flat roofs must have a 'h" 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.
HOMEOWNER'S NAME: /P�i'�d 17
ADDRESS: 7 e�3 7 //Iy P�✓s! 7�c.s,
RE-ROOFING COMPNAY NAINIE:
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-fooUwlnWord