R 6197 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 619 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
IZP 417-"Zd-_+Z% A0*1) R.9(46'
.9(4,( LV
. RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
,A� - YES ❑ If yes—I understand that a Class A
NAME(JIlAi V 161`100' T��AU6 UOJ.AeOWIJfi Ac,w root assembly is required.
^ NO C] Initial I.C.B.O.B
ADDRESS '81"N� EXISTING HOOFCOVERING
PHONE Mo'c ZrA"br4`0 NUMBER OF EXISTING COVERINGS $ LA-,164
CONTRA�r,TOR'S /7
NAME (&OA1SS 04417 120arWG 60. Itis_ _ TO BE REMOVED BE RETAINED
TYPE OF ROO6FF COVERING'
ADDRESS
-
clTYazIP Z2°IL LIrJG01,Q AUg S.S. gf:5my
/ EXISTING
PHONE` 461;� 44 S —06`1Jlb BUILT-UP ROOF ❑
LICENSE ❑ -
NUMBER � - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑ '
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
enact. �j �Q / WOOD SHINGLES ❑
License Class C.-3 ` LIc.Number �" •��tl
Data Contractor J24B3Atg4A1JC6 t.6% (a. OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION
Lice ION g PROPOSED /1
hereby affirm that am exempt from ins e: Any
License Law for the following reason. /J=l,
(Sec.7031.5,Business and Professions Code: Any dry or county which re,also a permit toconstrD
apyIcuot.alter,Improve,to file demolish, air statny ement
that he prior lolls Issuance,also the . BUILT-UP ROO ❑ D
of the
for such permit a file a signed r 9(commencing
that g with
Succi tl 7000)of
the provisions
of the Contractor's License Lew(Chapter a(commencing with Section 7000)of Division 3 0l the
• Business and Professionsof Code)or that he Is exempt therefrom and the basis for the applicant
to ASPHALT SHIN E$SEP 2 9[} 98
exemption.Anyviolationo t more
of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not mora then flue hundred dollars($500).):
Ll 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKE ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles- V
$Ions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGL l
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 '
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 Contractor's License Law does not PROVIDE I.C.B.O.REPORT
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 Contractors License law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data
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 self-Insure for Workers Compensation, �' Building�ZTI�O
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this r
permit is veanIssued. Seismic
have and will themaintain Worker's Compensation the workfor Insurance,as required by Section Worker's of "'111���
_Cho Lobar Code,for nce carrier
of the work for which This permit is leauetl.My Worker's �/
Compensation Insurance Gcarrie1r and Policy number are: Total 2�r ,O
Carrier r11 'fie r yt& Policy No. 61"'N47� 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section read not be computed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,I IQ J
any person in any manner so as to become subject to the Workers'Compensation Laws of 61( All roots Shall be Inspected prl o any roofing material 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: If,atter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Cotle,'you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shai0be deemed revoked. Sourc egulations.
I certify that I have read this application and state that the above Information is correct.I agree
to comply with sit city and county ordinances and state lawn relating to building construction,and All roY
erHlgS eclass°C"Orbetter.-
hereby authorize representatives of this city to enter upon the above-mentioned property for In. ///
spection
Wit) purposes. /J Z�r�yn
(We)agree to Save,pe Indemnity w antl keep hay a y cc Cly of Cupertino eggal-- liabilities, 7 ` 6
judgments,costs and expenses which may In any way accrue against saltl City In consequence
of the granting of this permit.. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS: I
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
i
HONEEOWNERSNAMIE: 0'a2DdnlutEW (�fa22PL� u0nn�ovJN�i2� Assoeta�o.a
ADDRESS;: ri/�IZ ZD� 7 �6 GA21�6� PLS Gf
REROOFING COMPANY NANI_: a TtE APPLICANTS SIGNATURE:
SEP 2 9 1998
CITY OF CUPERTINO
BUILDING DEPARTMENT BLDG. INSPECTION DEPART MEil i
CITY OF CUPERTINO
•
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