R 5632 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 6 3 2
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
pA Nyde RESIDENTIAL COMMERCIAL OTHER
OWNER'S C �M /� HAZARDOUS FIRE AREA
MU We11 � tli t 161 SES ❑ roof as embly understand Class A
NAME roof assembly is red that
NO fk Initial I.C.B.O.N
ADDRESS—a"" �1 EXISTING ROOF COVERING
O` '
PHONE 1 O a•� — NUMBER OF EXISTING COVERINGS v
CONTRACTOR'S
NAME ReS�ns0ble ploorT�l ,tn� \ 1 TO BE REMOVED TO BE RETAINED
CITY a z Pd,\l N• I����\ W0 � ilirn V(ew j TYPE OF ROOF COVERING
p.1 � EXISTING
PHONE �0 - -1I"1—(O 51 BUILT-UP ROOF
LICENSE ` n
NUMBER a�vlu ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES 131D
7000)of Division 3 of the Business end Professions Code,and my license Is In lull force and
effectLiven C 3d, WOOD SHINGLES (�Q ��p.''II r® s�
License Claes Lift.Number "l JAN 29
\ ' ICo-ai �e5pwnsibllc QMbjg� OTHER(SPECIFY) I� 4
Date OWNER-BUILDER
CITY /'`�VUr'�
OWNER-BUILDER DECLARATION PROPOSED CITY j 1J V
I hereby affirm that am exempt from the e: Any ore License Lew for the following reason.
(Sec.70315, ,Improve and Professions Code: Any city or county which requires a permit to
c.haapplicucl otter,Improve,demoto fire signed statement
eny mentrthat e,prior toitsissuance,to theprovi requires the BUILT-UP ROOF
of the Co lar such permit a Ills a signed statement that he Is licensed pursuant to the provisions
. of the ss an clots License Lew(Chapter a(commencingg with Section 7000)of Division 3 le the ❑
Business end violation of Code)or that he Is exempt therefrom and the peals for the alleged ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more then five hundred dollars($SOO)J:
❑I,as owner of the property,or my empioyeas 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 Contractor's license Law does not apply to an owner of property who builds or WOOD SHINGLES
Irl 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
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 coMractinpp with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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
with a contractors)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date - APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: a (� /h/-
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 1 - I,y— 1 f yl GY1 Building •'�
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this q tOkA
permit is Issued. Seismic
QI have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit Is issued,My Workers ')
Compensatiotn Insurance carrier and Policy number are: Total f�
Carrier�ll0\dem l-�.vt\P Policy NmtA 6411003"'02 PER ORIZATI DATE
CERTIFIC FROM WORKERS'
COMPENSATION INSURANCE N.C.I] w — 4 /1
(This section need not be completed if the permit Is for one hundred dollars($100)or IsesJ _ /�77 lf•G•�i
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 sh a inspected.p or to any roofing material being
1°`"la. II� [ installed f a roof is installed without first obtaining an
Date \'\�o' v Applicant f"1/y"` inspect' n,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter 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 Coda,you must forthwith comply pP p y p
with such provisions or this permit shall be deemed evoked. Source regulations.
I certify that I have read this application and state that the above Information ie correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All rpof coverings to be class"C"Or better,
hereby authorize representatives of this city to solar upon the ebovemenlloned property for In.spectl
�' i- ,vx
hereby
purposes. IL.rCI/lN/./'IAt YI//lY/II 1
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, r/� 1 �,(Q —q sr
• judgments.vests end expenses which may in any way accrue against said City In consequence
on he gmnung of figs permit. SIGNATURE 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 y'
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DE?.4a7ME`IT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PYASE.
1. Prior to per issuance, you must agree to comply with U.B.C. s andards and manufac ues spec's
on «rcofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written acoroval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the re:eofing 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,) P:einspectioa or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector veriflation
• b.) Spark arrestor installation
5. If plywocd is installed,a plyweod 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 inspec all sheathing at that time.
WE UNDE, STAN THE ABOVE FOLICY ON REROOFING AND WILL CON[PLY WITH T"M
POLICY
_ HOMEOWNERS NAME: 1'�0�Y`We11 SI0YY�IC`'1
ADDRESS; �y d e
REROOFING COMPANY NAME: 2S O b1e oU�l
APPLICANT'S SIGNATURE:
s
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Rerooflwinwdrd