R-5807 PERMIT
APPLICATION FOR clTv of cuPERTINo
NUMB R R- 5 8 0 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
fit RESIDENTIALXV, COMMERCIAL OTHER
OWNERS/1 C� s� z� .r-- AZARDOUS FIRE AREA
NAME �+7' PUS 114 f ll-'T"•C6"r.T N E / K l SES Cl❑ fact as embly i understandthata Class A
roof s-I undo Is required.
s NO Initial I.C.B.O.#
ADDRESS 10 2� R EXISTING ROOF COVERING
PHONE �-� Z.( NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
K '}� D
NAME EA-L TMJT� ��I'L IlE-QR���C�A.�� TO BE REMOVED / TO BE RETAINED
ADDRESS r1_ � 114 TYPE OF ROOF COVERING
clrvazlP SO 70 EXISTING
PHONE 'g9e. "2-3 q� BUILT-UP ROOF ❑
LICENSE
5/ 31883 ASPHALTSHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' �p WOOD SHINGLES `36�❑
License Class Lic.Number `
OTHER(SPECIFY)
Date Contractor ¢
NER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law far 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
• of the Contractor's License Lew(Chapler 9(commencing will 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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500)J:
❑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(Sec.7044,Business and Proles
alons 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,provitletl that
such Improvements are not intended or offered for sale.If,however,the building or Improvement -
issoldwithinOneyearofcompletlon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
p I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
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.
❑1 am exempt under Sec. ,B a 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: a �1
`71 have end will maintain a Certificate of Consent to sell-Insure for Worker's Compensation. P /`lp1 l I ® p y Building
asprovidedfor bySection 3700ofthe Labor Code,for the performance of the work for which this n 11
permit is Issued. 9 2 1 0 � Seismic I
F7I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of DEC 19 r
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Total
Compensation Insurance carrier and Policy number are:
Carrier Policy Na _llI?ERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(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 issued,1 shell not amploy,
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots she be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date Applicantyr� inspection,I agree to remove all new materials for inspection.
NOTICsubject toEto the Workers'Compef,after nsallon provisions of theicate of Laborr Code,Exemption,
must fothwlitthbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shafts deemed revoked. Source 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 ordinances and state laws relating to building construction.and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep purposes.
we)
(We)agree to save,expenses
and keep harmlessyway the Clry ai Cupertino against n liabilities,
ence _G"f
• of the gran,costa and exposes which may In any way accrue against said CIN In consequence
of the granting Of This permit. SIGNATU APPLICANT DA E
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 _
CITY OF CUPERTINO - BUILDING DEPARTMENT
RE-ROOFING POLICY
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections and written
approval from the building inspector. A final inspection and approval shall be obtained
from the building inspector when the re-roofing is completed.
3. All types of roofs shall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1,2. and 3.
I. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
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 sheating and a building inspector will inspect all sheating at
that time.
IMPORTANT:
1. Flat roofs must have a ''/A" per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE POLICY.
HOMEOWNER'S NAME: St F I GE (S H ; S AQ,4N6 A NET-KE
ADDRESS: 10,56 / GLEN UIEUO"DRIU �
RE-ROOFING COMPNAY NAME: E0 L—T EC p i�a_ (QS�wICrS
APPLICANT'S SIGNATURE: " G
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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