R-4943- _0
•
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR
OFFICE COPY
PERMIT4 3
R- 49
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
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�(Q
10,650S ��
t� -
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
pp�.,yL!� ,I
Ili
YES ❑ If yes- I understand that a Class A
NAME t`µ `'V 1�e t�wl
roof assembly is required.
NO Initial I.C.B.O. #
IO G % a2k.Ls Fvfe•
EXISTING ROOF COVERING
ADDRESS
PHONE -
NUMBER OF EXISTING COVERINGS I
TO BE REMOVED I TO BE RETAINED O
CONTRACTOR'S
NAME J6VA4?S IJ. S ut' Jr. g00'R w
ADDRESS
29c1 D B�ss�{tS SJ• RSuD
TYPE OF ROOF COVERING
CITYaZIP
EXISTING '
�
PHONE ;?.701— 6120
BUILT-UP ROOF ❑
LICENSE
NUMBER (0 7091
ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
]000)of Division 3 of the Business and Professions Code, and my license Is In full force and
effect,
/
c3 q (01:07991
(/
WOOD SHINGLES 3
License Class 1 Llc. Number
b ' t ` Ste.
OTHER (SPECIFY) �]
Data
PROPOSED
OWNER -BUILDER DCLARATIO
I hereby affirm that I am exempt from the Contractor Licens° aw for the following reason.
(Sec. ]031.5, 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 Elapplicant
far such permit to file a signed statement that he Is licensed pursuant to the provislons
of the Contractor's License Law (Chapter B (commencing with Section ]000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES v ��
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 ($51
WOOD SHAKES
❑ I, as Owner of theproperty, or my employees with wages as their sole compensation, will d0
❑
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 tar 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 (See. 7044,.Business and Professions Code: The Contractor's License Law does nal
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 contractions) 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 following declaration:
C]I have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which thIll /
Is Issued.
21
Building (�
permit
1996
Seismic
55��I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
to bor Code, for the performance of the work for which this permit Is Issued. My Worker's( r �r
�Q,�,�y)
C/"/
-Compensation Insurance carrier and Policy number are:
LI/YCrtf IIYI)
Total
Q`, f^tpp
Carrier AIG �S• PollcyNo. �4Z0190
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
/
(This section need net be completed It the permit Is for one hundred dollars ($100) ar lessJ
•iV�
I certify that In the performance of the work for which this permit is Issued 1 shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
All roofs shall be inspected prior to any roofing nnterial being
fornia,
installed. If a roof is installed without first o taining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Certificate Exemption,should
NOTsubject lI. eOWorrker°CC mpensiion provisioone
Applicant understands and will comply with all non point
thCE
of the Labor Code, ou must forthwthbecome
comply
with such provisions or this permit shalfbe deemed revoked.
Source regulations.
I certify that l 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,end
OOf overings to be 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 flab ties,
sU • (.121 1,96
judgments, costs and expenses which may In any way accrue against said City In consequ.n
IC,DAT
of the granting of this permit.
T
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
OFFICE COPY
0
r�L
n
LJ
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.
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 AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME:
ADDRESS:.
REROOFING COMPANY NAME
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword
F—A Mc M.4�x
w 6So 4 k s Ave