R 6193 PERMIT
APPLICATION FOR clTv of cuPERTINo
NUMBER RSS 6193_J
INSPECTION DIVISION I PERMIT EXPIRATION
REROOFPERMIT (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 ,/ r, ,, �
I U &A •WrJ '1�A , e Tj 1Ja - RESIDENTIi COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME A �.N VIffVJ �vr[.1c.+n� Poineowjgg A __ roof assembly is required.
� NO El Initial I.C.B.O.If
ADDFiESSSA,,.rs"` EXISTING ROOF COVERING
I
PHON S 10 - NUMBER OF EXISTING COVERINGS LAYS.
CONT A OR'S �J //
NAME') A"e_ZAN C,< ap&r— it C..D - 10C_ TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF'ROOF COVERING
B Z P -°IZ L 7zwrmL N /AV cT , ,I'>j.s', , a 5(?..b'
CITY ,�,�nEXISTING
(4,05b `
PHONE � � 40y.—Q6Cli-4 BUILT-UP ROOF ❑
LICENSE �3�
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Divislon 3 of the Business and Professions Code,and my license Is In lull force and
effect, ix T���a WOOD SHINGLES ❑
License Class QC'�3� LIc,Number �VAT7
Date �'�� `K Court racmr--4iNJA>I,4MNrd 124VI . Co. OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's or roue Lew for the following reason.
(See.7031.5,,Improve and demolish,
or rep Code: Any city or county whuh requires a permit toconstr0
applicant
Lor altar,Improve,to file asigedstapair eny mentrthate prior taIts laersuantelstheproreathe BUILT-UP ❑ D
applicant for such permit a flaw a signed statement that g it licensed pursuant to the provisions the
of the Contractor's License Law(Chapter B(commenting withSectionand the b of Division 3 of me f 93 291910
•
Business and Professions Code)or that he Is exempt therefrom end the beefs far the alleged ASPHALTS L ,Sn
exemption,Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 1a ti-
a civil penahy of not more than five hundred dollars($500).): WOOD SHAq S
❑l,as owner of the property,or my employees with wages as their sole compensation,will do 1 ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHIN
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
la sold within one year of completion,the owner-builder will have the burden of proving that he did. OTHER(SPEC Y) ❑
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 Lew does not PROVIDE LC.B.O.REPORT NOt2� `i 4CZ b'7
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sac. ,B It 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:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, ^� Buildin x? QO
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1' Z°i-I�G /�.�x /�/�
permit is issued, 4:1� I LLJ' VL Seismic
0I have and will maintain Worker's Compensation Insurance,as required by Seclion 3700 of
„the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 1;2
Compensation Insurance carrier and Policy number are: Total 2
Carder FUNIS Policy No, SNA b PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ o
(This section need not be completed 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 issues 1 Snell not employ d
any person In any manner so as to become subject to the Workers'Compensation Lawn of can- All roofs shall be inspected prior to any roofing Material being
fornla. 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,after making this Certificate of Exemption,you should become Applicant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shellibe deemed revoked. soursregulations.
I certify that l have read this application and state that the above Information Is correct.I agree (79�J)����
to comply with all city and county ordinances and state laws relating to building construction,and AllWNATCUR
erincwt4'7be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,tooQmems,coats and expenses which may In any way accrue against said Ciryofflegranting of this permit. SI E 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
SUBIECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTNIENT
PRIOR TO ISSUANCE OF PEANUT AND INSPECTION PHASE.
I. 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 COLLA WITH THE
POLICY
i
HOi IEOWNERS NAME: tG �^�t/t � � uoN lTbw�'6rLS AyS�tA0iv�1
ADDRESS:: : 1 I�{ l0 l t44 b �711�� siJ X62 D�
REROOFING COMPANYNAME: c a tq�ec� eyofv L60. I)je.—
APPLIC,6uNTS SIGNATURE: —
����
SEP 2 91998
CITY OF CUPERTINO
BUILDING DEPARTZ(FNT
SLOG.INSPECTIONIOF CUPERTINO MtN
Reraof/winword