R 5481 (2) r.
APPLICATION FOR clTv of cuPERTINo
NUMBER R- 5 4 H Z
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
S—FeVe H S. CCgh Y6 vi RESIDENTIAL COMMERCIAL OTHER
OWNER'S n HAZARDOUS FIRE AREA
De-eq h J a'y Ye YES ❑ If yes-1 understand that a Class A
NAME Roof assembly Is required.
NO Initial I.C.B.O.e
-
ADDRESS— (4, EXISTING ROOF COVERING
PHONE
Lil-0 O ' '2-S 5 6t LL4 NUMBER OF EXISTING COVERINGS J
CONTRAC R'S
NAME e n� 'SSnI� << e>t, TO BE REMOVED / TO BE RETAINED
TYPE OF ROOF COV
ADDRESS 2 2'j 2 ERING
CITU 8 ZIP EXISTING
PHONE 4-O(Fy _4 �� � 6 �-7 BUILT-UP ROOF LY
LICENSE ❑ '
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION �-
herf Ol iston that em licensee under Professions
loan of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Divlalon 3 of the Business and Proleulona Cotle,and my license le In lull force and
effect. G,3--� SS----1"73 6o WOOD SHINGLES 1 9fJ-
License ClaesLlc,Number
Data C!
1�- Contractor OTHER(SPECIFY) 1-1
OWNER-BUILDER DECLARATION PROPOSED
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 11applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 0(commencing with Section 7000)of Division 3 of the
Business and antl 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 dolls is($500).):
❑I,as owner of the properly,or my employees with wages as their sole compensatlon,will do WOOD SHAKES
the work,and the structure Is not Intended or offeree for sale(Sec.7044,Business and Praise.
alone Code:The Contractors License Law does not apply to an owner of property who builds or ' WOOD SHINGLES ❑
Improvas thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner.bullder wilt have the burden of proving that he die OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code;The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensee pursuant to the Contractor's License Law. - PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
hereby and under penalty of perjury one of the following duce(or Wo
❑ have and will maintain a of CertificateofConsent toeperformafor Workers Compensation,which
this pa Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this Y'
permit$I.aauetl, SBI
jl7abor end will maintain Workers Compensation Insurance,as required by Section 3700 0l DEC Labor Code,for the performance of the work for which this permit Is Issued,My Workers ■ 4 �� Total \
'Compensa[llo-the
and Policynumber are: sit d� '7 Avl�(t/
Carrier `-' 1 _ �K2 Policy No. Lo .9—� / (Ij�{q T.AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1,61] "w I t_f If"1
(This section need not be completed N the permit Is for one hundred dollars($100)or IessJ L.*,C 1
I certify that In the performance of the work for which this permit IS Issued,I shell not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Cel(- All roloi shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions of this permit shalfbe deemed revoked. source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances andelate laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In. //�"/�' /��� // 1^^ //'' !
ep(we) purposes. .l V \ r�"ILcvu�(�� leC�`�1 -7
(we)spree to save.Indemnity and keep harmless the Clry of Cupertino agalrmt liabllence
judgments,costa and expenses which may In any way accrue against said Clty In consequence SIGNATURE OF APPLICANT _ . - - DATE
of the granting of this permit.
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
• 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 sheat ing and a building inspector will inspect all sheating at
that time.
IMPORTANT:
1. Flat roofs must have a V4" 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: eU t^ Sa yf e
ADDRESS: I d 80 S S . V•e tis (fA t"yav, IQ
RE-ROOFING COMPNAY NAME: �etnoi `SSA' cc �oo/F�iw/�oJ
APPLICANT'S SIGNATURE:
. CITY OF CUPERTINO
BUILDING DEPARTMENT
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