R 5841 (2) .; PERMITR" 5841
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
1Bo DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSQ�/
Q 7 /' RESIDENTIAL COMMERCIAL OTHER
OWNER'S/S++,�..,, HAZARDOUS FIRE AREA
NAMES�f7M ONE O� CIV YES ❑ Ilyes—Iunderstandthed. Class `
/mfr fi.�o 11 a—I required.
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE 7�3 6Q to ,. NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
G- S /CP�F/M/� TO BE REMOVED TO BE RETAINED
NAME Z-0.9
ADDRESSA TYPE OF ROOF COVERING
CITY&ZIP—�'O• 1L 173 ��4,mS 6!11 Irv?/ .
EXISTING
PHONE 3s�--��✓7,? BUILT-UP ROOF - ❑
LICENSE
NUMBERLICENSED C - ASPHALT SHINGLES ❑ -
ONTRACTORS DECLARATION
I hereby affirm that I am 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..
License Class C/3 `f 4 9S'3 q C WOOD SHINGLES
Lic.Number
Date ContractorOTHER(SPECIFY) � ]
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm(hat I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,eller,improve,demolish,or repair any structure,prior to its Issuance.also requires the BUILT-UP ROOF ❑
applicant for such permit to fits a signed statement that he Is licensed pursuant to the provisions
. of the Contractor's License Law(Chapter 9(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 (� L
exemption.Any violation of Suction 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,of my employees with wages as their sole compensation,will do WOOD SHAKES ❑ r�Z
the work,and the structure is not Intended or oHeretl for sale(Sec.7044,Business and Profes.
sions 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,provided that
such improvements are not intended or oHeretl for sale.IL 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) p
not build or Improve for purpose of sale.). i+
C]1,as owner of the property,am exclusively contracting with licensed contractors to construct 7
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of props rty who builds or Improves(hereon,and who contracts for such projects �����y/ q�
with a contractor(s)licensed pursuant to the Contractor's License Law.
E] P. PROVIDE III INB•I�'►HATIC7 SPECS.
I am exempt under Sac. ,B& C.for this reason
Owner Date APPLICATION DATE V(iUUArtION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby aBlrm under penalty of perjury one of the following declaration: -
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building 1"i
as provided lar by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit is Issued.
C] SeiBmID
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
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 AMF1SCAM PA19-=OT Policy No. 51W� OSIo49SoD PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars fill W)or less.)
I certify that In the performance of the work for which this permit is Issued,I shall not employ U
any person In any manner so as to became subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data Applicant RM 1 17i:iaiL inspection,I agree to remove all new materials.for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you muni forthwith comply pP p y p
with such provisions or this permit shalCbe doomed 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 BlBlo 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-mentlonod property for In.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, -
. .I the gnts,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT NT DATE
of the granting is this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION, G BATTENS: FINAL:
INSP. d DATE66 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 ''/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: l'_�yiSew.s of C�u�S✓J�i�%�
ADDRESS: !0 0 4 Gdreittiss /J i
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE: f, / :��� i
MAY 29 1999 ` D
CITY OF CUPERTINO
• BUILDING DEPARTMENT isLUU. INSPECTION DEPAH i iviriv i �9 pNS'�
CITY OF CUPERTINO �A
Re-roof/winword Ctty