R 5500 PER
IIT
rUMBE
NR R- 5500
APPLICATION FOR CITY OF CUPERTINO
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
Ceavra -Teresa Dr ve
RESIDENTIAL COMMERCIAL OTHER
OWNER'S J - HAZARDOUS FIRE AREA -
M/M [G f/ VI U Ll r-el) YES [:] _It yes—I understand that a Class A
NAME roof assembly Is required.
NO Initial I.C.B.O.It
ADORESS'''�'^^ami e /� EXISTING ROOF COVERING
PHONE TLS o ( — S l NUMBER OF EXISTING COVERINGS
CONTRACTOR'S- SSG C 2 fl C>_ /- k TO BE REMOVED I TO BE RETAINED
NAME 'e �� I K CJ`f"�
ADDRESS 22��. yt C a ,�. TYPE OF ROOF COVERING
CITY&ZIP EXISTING
GOfs - /fy
PHONE 7 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES e
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. C 3 SS,1-73 6 WOOD SHINGLES ❑
License Class Lid.Number
Data
_01�4jt'--1 7
DeOtraCler OTHER(SPECIFY) ❑ _�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for 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 provision:
of the Contractors License Law(Chapter 6(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 ' - ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑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 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 ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement pUI-a 1,-te
Iseold 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.). IJ
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct 20 3
the project(See.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 bul ds 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.
I am exempt under See, ,B&P.C.for this reason
Owner Date APPLICATION DATE - VALUATION PERMIT FE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ have and will maintain 37 a of the Lab of Consent or to self-Insure performa for Worker's Compensation. D BNilles provided havefor by Section 3700 of the Leber Code,for the performance of the work for which tole
permit Islasued.
5s Kava entl will maintain Worker's Compensation Insurance,a:required by Section 3700 o W SmICthe Labor Code,for the performance of he work for which this permit is lasued.My Worker .. 27ns Comperes Ion Insurannce terrier antlPolicy number are; xIC(r-o T
Carrier— ` r �U Policy No. —! 7 �E T AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(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,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be illSpeCted prior to 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: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp p y p
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 taws relating to building construcllon,and All roof coverings to be class"C"or.better.
hereby authorize representatives of this city to enter upon the above-menticned property for In. ^
spection purposes.
(We)agree to esus,Indemnify and keep harmless the City of Cupertino against liabilities,
oftlhe granting ofcost.hie permitan , SIGNATURE
which may In any way accrue against said City In coneequenco SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.—DATE—- 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
-'y 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 '/4" 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: M IM 4:fUV\AAy i
ADDRESS: ro �5 �1 O
RE-ROOFING COMPNAY NAME: Pe P1 0 ' S SG to Ce 2 t, cl
APPLICANT'S SIGNATURE: Zf> Ca"d " Qy
• CITY'OF CUPERTINO
BUILDING DEPARTMENT
RerooOwinword