R 6198 PERMIT R_
f' APPLICATION FOR CITY OF CUPERTINO NUMBER 619 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228' PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
�j �e �[
2a-Z20i. L-��)� Ujg2 Q� eJ_ RESIDENTIAL " COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/I,,1� YES ❑ If yes-I understand that a Class A
NAME 4 A1&N6&)V1610 _r69CA d H0&,1r&.J -J!4 ACCA roof assembly is required.
No ❑ Initial I.C.B.O.N
ADDRESS 7AMd EXISTING ROOF COVERING
�..�1
PHONE �O� NUMBER OF EXISTING COVERINGS 1. LA754
CONTRACTOR'S - u
�QI� - f2 Q r TO BE REMOVED t•' v TO BE RETAINED
NAME_IC6JAr�},oAroG6 IC-QOfWQ l.0 - ylrJ(,.
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 2Z4L UNC61,0 Aum S-1. r gS)ZT
EXISTING
PHONE ¢4Cc —OC� BUILT-UP ROOF
LICENSE
NUMBER 5���'3P,o ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES -
7000)of Divlslon 3 of the Business and Professions Code,and my license is In full force and
affect.
❑
License Claes C-39 Lia WOOD SHINGLES Number ��
Dale 9-71_1 it Contractor J21&)At10;ANc& (ZoeF rWCn (e OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors 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 71
applicant for each permit a lila a signed statement that he Is licensed pursuant to the provisions I a
of the Conor such
License Lew(Chapter t teommahat h with licensed
7000)of Division 3 0l the
. Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHING
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to D
a civil penalty of not more than five hundred dollars($501 WOOD SHAKES �'
❑I,as owner of the property,or my employees with wages as their sole compensation,will do q •I(�(�e
the work,and the structure is not intended or off2
offered for sale(Sec.7044,Business and Profes. SEP IJJV
sions Cotle:The Contraolor's License Law does not apply to an owner of property who builds or WOOD SHINGLE Elim roves 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,thewner-builder will have the burden of proving that he did OTHER(SPECIE By Elnot build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.AS7''n
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
EJI am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BW ldingZZT�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this '�� n. Q-7
permit is issued. D`� Seismic
a have and will maintain performance
Workers f the work
for Insurance,as permit
by Section orkeof
3, 72y
the Labor Code,for the pertormand of the work r a which rola permit Is Issued.My Workers
Compensation Insurance carrier and Policy number are: Total ZXRO•7Y
Carrier gT'�G� fUIU� PoncyNo, lrJa 771 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION. WORKERS'
COMPENSATION INSURANCE NA.O 3
(This section need not be completed if the permit Is for one hundred dollars($100)or leas.) hA�TJw.ClCC r / L Q
1 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'Compensation Laws of Cali- All roofs shall be inspected prior to any rooling m terial being
tornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP p y p
•with such provisions or this permit shall be claimed revoked. souAce regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county oMinances and State laws holding to building construction,and All of OyrCOe Class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for in. 5/�/
sp(Wit) purposes.
(We)agree s save,expenses
and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against sold Clly In consequence
of the granting of this permit. S NATURE OF APPLICANT 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 PEPWIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.H.C. standards and manufacturers spec's
on reroofing.
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 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 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 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: koAaowN6f .G A-Aoeimnoo
ADDRESS:: : Z bq 1�, A(L1�tJ C.¢6-r-V
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING OEPARTMIENT
gEP 919
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