R-56221]
0
OFFICE COPY
PERMIT
R- 5622
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.
BUILDING ADDRESS
Orah Ly,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
LII ` /
YES ❑ It yes— I understand that a Class A
NAMET�///��I /� ir'
NO ❑ roof assembly is required.
Initial LC.B.O. N
�/�
EXISTING ROOF COVERING
9-5 We5s-e x 2_0S OS
ADDRESS' / µw l'r/l
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
Irs
_/ GPHONE / `
CONTRACTOR/'$�, y//� �n q
Gafa �Q
NAME L�(JS s B V IY L V'
ADDRESSTYPE
ZIP - -0 Bay, 172
OF ROOF COVERING
CITY &ZIP
EXISTING
s ' /2,3-3
PHONE
BUILT-UP ROOF pr
-3
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensetl under provisions of Chapter 8 (commencing wit n
OOD SHAKES ❑
7000) of Division 3 of theBusiness and Proleaelone Cod ,entl my Ilcen e i/ lull brG e�
effect' S3 /!Y/
WOOD SHINGLES �p ❑
License Class Llc. Number
4/0❑
OTHER (SPECIFY,
Date Contractor
�'�A
OWNER -BUILDER DECLARATIONPROPOSED
hereby that I from the Contractor's License Lew for the following
CI%�. iI �sA
affirm am exempt reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit t0
O/C
construct. alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
for file he Is licensed
V
BUILT-UP ROOF Lvr;. Elapplicant
Q
such permit to a signed statement that pursuant to the provisions
of the License Law (Chapter B (commencing with Section 7000) of 3 0l the
for the
ss and Code) or that he Is exempt therefrom and the basis far the
Business entl
ASPHALT SHINGLES V
on Of Section by any applicant for a permit subjects the appllcent to
exemption. Anyviolationo to
violation of applicant
t hundred dollyeesrs
e dull penalty of not more than live by
WOOD SHAKES
1, as owner of the property, or with wag.):
employees rages(Stheir Compensation, will
❑
teemployeeswith
the work. and the structure Is not Intended or offered for eels (Sea 44, Business entl
sipneCotle:The, owner of o-
License Lew does not apply t0anowner ofproperty whooidedtor
builds
WOOD SHINGLES ❑
and his Own employees, provided
e9 thereon, entl who does such work himself or
such I .11, how
such Improve menta are not Intended or offered for sale. ant
however, the hulloing or Improvement
to sold hinill have the burden cl provingthat hadid ,
OTHER (SPECIFY) ❑
stheowner-bulltlerwlll
or prove for purpose
not bulltl or Improve for purpose of sale.).
not
D I, as "nor 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 NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
ry
with a contractor(s) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
E]I am exempt under Sec. ,B & 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 following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compensation,
Building
as provided for by Section 37W of the Labor Code, for the performance of the work for which this
PRr�it Is Issued.
`m I have and will meinaln Worker's Compensation Insurance, as requl red by Section 3700 of
tT 1/'
�'
�� �O�%
Seismic
tha'Cabor Code, for the performance of the work for which this permit Is Issuetl, My Worker's
Total
Compen/§��jt�ion I aura a carrier end Policy number are:
camerld6� Q%j /2 Policy No. �
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed 11 the permit Is for one hundred dollars ($100) or leas.)
1 certify that in the performance of the work for which this permit Is Issued, I shall not employ
any person in any manner so at to become subject to the Workers' Compensation Laws of Call.
All roofs shall be inspected prior to any roofing Material being
forma.
installed. If a roof is installed without first obtaining an
�_�y�
Data 7- Z`�' "' 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 comply with all non point
pP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shell be 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 co gs to be class' better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
! �"7 ,Z
agree to
(We) spree to save, Indemnity and keep harmless the Clry of Cupertino against Ilebllltlea,
�yyr� /' PI
gents,
jutlpments, costa and expenses which may in any way accrue against said City Inconsequence
ATURE OF LI DATE
of of this permit.
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 CUPERTNO BUILDING DEPAR"PIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply wih U.B.C. standards and manufac req sec's
on reroofing.
2. New roof coverings shall not be noplied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be cotained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof be; installed.
4. In order to receive a final, you must complete steps 1, 2, and 3.
1,) P:eiasTection or tear off approval.
2.) In progress inspection approval.
;.) Final inspection approval.
a.) Operable smoke detector verification
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 PSID WILL COMPLY WITt. TJr=
POLICY
HOMEOWNERS NAME: L U
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTZ[ENT
•
Rerooflwimvord
LoS
O