R 6184 PERMIT R_ 618 4 .
APPLICATION FOR CITY OF CUPERTINO [NUU
MBER
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 . / , � t)"C,(�
51VAP1L� ' RESIDENTIAL--X— COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�� ' VES ❑ If yes s I assembly
steed that a Class A
NAME--J, '?' ooC rf"GG ttt��� NO roof essemMy is requiredfifil. -
066 / �UIV�I �� ❑ ROOF
I.C.B.O.N
ADDRESS '7 V 1 / EXISTING ROOF COVERING
PHONE Z �2-4-� 1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �✓� S /'I �N I TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBEa ASPHALT SHINGLES VaLe�aC�—/
LICENS licensed under RACTORS DECLARATION
1 hereby affirm Ihaf I em usisunder Professions
of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Proleacions Cotle,and my license Is In lull force and '
effect.
WOOD SHINGLES ❑
License Class Lic.Number '
DateContractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors 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 ❑ ZZ
applicant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter g(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 Proles-
alone Code:The Contractors License Lew 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 Bale,If,however,the building or Improvement
Is sold within One year of completion,the owner-builder will have the burden of proving that he didOTHER (SPECIFY) ❑
not build or Improve for purpose of sale.). /
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See.7Vn ,?
ese and to salons Cotle:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an liarwho fou ser improves thereon,and who contracts for such projects $ O
with a cont tpursu to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 an, ) ,B&P.C. r ihl reason _
i
Own-41' Dete APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I he y affirm under penalty of perjury one of the following declaration:
❑1 ave and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, /Q� Jv Building 17100
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 5�
` permit is Issued. O O J
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic .�O
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total 9 7.S.v.
Carrier Policy No. _ PERMIT AUTHORIZATION DATE
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ _ g w J
(This section need not be eompletetl 11 the permit Is for one hundred tlollere($700)or lase.) OC �J 4�
I certify that In the performance of the work for whic a mit le Is aq I shall not employ
any person In any manner so as to become ruble to r nl Co ensatlon Laws of Cali. All roofs I be I ed p I r 10 roofing material being
forma. installed I a r f is nsta ed w ut first obtaining an
Date 10� A oeent ins ecti a rfE1�E7iTD r mov yy�e terials for ins ection.
NOTICE O A PLICANT: Il,eftepr making Is Certificate of Exemption,you should become AID plicae ndBfSf an lY C I p
subject to the Workers'Compensation provi na of the Labor Code,you must forthwith comply y with all non point
with such provisions or this permit shall be earned revoker!. Source r ulaho S.
I certify that I have read this applfcatlon and state that the above information Is correct.I agre
to comply with all city and county ordinances and state(aw$relating to building construction,and AIIr f g tobe lass"C"orb Iter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
specelon purposes. �-
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
jollheents,grancosts
of andthis expenses which may In any way accrue against avid City in consequence 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
SUBfECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPART v(ENT
PRIOR TO ISSUANCE OF PERNaT 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 shalt 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 COMPLY WITH THE
POLICY 1
HOMEOWNERS NAME: , t /'//,�� {/� cc� /�
ADDRESS:: : -.L/(!Ab / d W,,6
REROOFING COMPANY NAME: 1
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTi ENT
•
Reroof/winword