R 6194 PERMIT R_ 619C
.
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.
BUIL/DING ADDRESS �(
(0 Q([ CI^ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
x YES ❑ If yes–I understand that a Class A
NAME GAIUS60YI(�t3 I-ILI'K.ES r'bM�OWN11+2� �{�y(xOG; roof assembly is required.
NO ❑ Initial I.C.B.O.M
ADDRESS EXISTING ROOF COVERING
'',�
PHONE La•� �(p//(;'161 C) NUMBER OF EXISTING COVERINGS I.AY6+L
CONTRA/�/yT�OR'S ,, �7
NAME I dA' �OFIaG, Iib I N(,• TO BE REMOVED TO BE RETAINED -
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP 229\2 LINC.61 o Avc3- -E S�IZS EXISTING
J
PHONE (+QSs 4+? —0001 BUILT-UP ROOFLICENSE
zJ ❑
NUMBER r'JS (zt'3Po ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License Class L– Us.Number 'eD
Date
9-7, Contractor N
9—gT &AA." OTHER(SPECIFY
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED Lam"
(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 raquires the BUILT-UP ROOF SEp 2 �1g9sa
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions Lr
of the Contractors License Law(Chapter 8(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 ASPHALT SHING $
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).1:
❑I,as owner at the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Bx1-
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles. 1
sions Code:The Contractor's License Law 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.If,however,the building or Improvement
lssoId 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.).
01,as owner of the prcperty,am exclusively contracting with licensed contractors to construct M 9jL/C z
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO./947
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration: '
I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building �ft7•oC
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this qqq ty
permit Is Issued.and (���� seismic Z 1 y
have and will the performance
Worker's Compensation the wokfor Insurance,as requiredsu Section$700's l _ I l( J f0
the Labor Cotle,for the pedormance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: �— Total ��,9 y
Carrier S17AMa Fill Policy No. DIhT PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑
(This section need not be completed It the permit is for one hundred dollars($100)or less.) e Jq.(JGC• `� Zy
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 o the Workers'Compensation Laws of Cali. All roofs shall be inspected prior-to any rooting terial being
fornia. 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: Il,after making this Certificate of Exemption,you should becopm� Applicant understands and will comply
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith com I pP p y with all non point
with such provisions or this permit shell be deemed revoked. Source regulations. -
I certify that I have read this application and stale that the above Information Is correct.I agree Te
to comply with all city and county ordinances and state laws relating to bulltling construction,and AlIIngS Obe Class„C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for in.
spection purposes. 4���-n
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
• or the granting of this permit. SIGNATURE 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 PERMIT 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 wricen 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.
• 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: nAVW ) Wn1M ARVI 0,J
ADDRESS; : w6Q5 - -LOWI 61ACb5f-) MAW4 ('7
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE: p
CITY OF CUPERTINOLN1
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BUILDING DEPARTMENT BI�G'111SP OFG1IP��S�OM
• OIS� I
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