R 6196 _ .. PERMIT R- 6196
APPLICATION FOR CITY of CUPER- NUMBER
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (�
0�l - Zoe 35 G A2A6r3 Y C71� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
w / VES ❑ If yes—I understand that a Class A
NAME rA,2LtbN!I '7 12Aeff NO roof assembly is required.
NO ❑ Initial I.C.B.O.tl
ADDRESSg14f'^�' /Q' EXISTING ROOF COVERING
PHONE tree �4 sem O NUMBER OF EXISTING COVERINGS + I"lym
CONTRACTOR'S �l
NAME IL6AW.01--q N0e f.Q2nnQ, l 0 IA�G. TO BE REMOVED TO BE RETAINED
J
ADDRESS / TYPE OF ROOF COVERING
CITy B ZIP-22�1Z Litijm_P3 AV5- �S S, , -1 C,17_6
\ A A TTEXISTING ,
PHONE _L4'01 J �—b6°I_4- BUILT-UP ROOF ❑
LICENSE
NUMBER ��(o ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
License Cl...
6_3ytLic.Number WOOD SHINGLES ❑
� � '
Date -�/ Contractor �^4yA1g'SA1Ji 1G/�OAGIN6& OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the following reason.
(Sec.hereby
Business and exempt
Professionsfrom Code: Any city or county which requires i permit to
n.
construct,alter.Improve,di 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 D D
of the Contractor's License Law(Chapter B(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 SHINGLES 2 9 1998
exemption.Any violation of Section 7031.5 by any applicant lora permit subjects the applicant to Q
a civil penalty of not more than five hundred dollars($500).1: �7
❑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(Sac.7044,Business and Profes.
sions Code:The Contractors 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 By ❑
such Improvements are not Intended or offered for sale.If,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) El
build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with Ilcensetl contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO qV-'V 93H6 2 W
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
O I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this Z
permit is leaned. q y I_ 9-�ij 7Z Seismic s.
MI have and will maintain Workele Compensation Insurance,as required b Section 3700 of 1
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance camorr and Policy number are: Total
Carrier 4;r1 sur� FyAb Policy No.BL4 _ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE N . q �/
(This section need not be completed If the permit Is for one hundred dollars($1021)9r lase.) ti,70ti
I certify that In the performance of the work for which this permit is Issued,I shall not employ U
any person in any manner so as to become subject to the Workers'Compern aton Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
0810 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption.you should become
subject to the Workers'Compensation provisions of the Labor Coda.you must forthwith comply Applicant understands and will Comply with all non point
with such provisions or this permit shall be deemed revoked. sour 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 ordinance.and state laws relating to building construction,and Allf f vein be CIRSS"C"Of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, OV
judgments,coats and expenses which may In any way accrue against said Clty In consequence
. of the granting of this permit. 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 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 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
• 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: r�9i" n� t l t Fsu1 �GrLZ�LC� (�oMdbwN�tC L p�oURPtOn1
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
\\SGS"', 91Q�
CITY OF CUPERTINO she-04���\\Ao -
BUILDING DEPART Z ENT e`�G�Gg' OF GAP
•
Reroof/winword