R 5803 (2) PERMIT R_ . 5803
APPLICATION FOR CITY of CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
10'6215 STUF. 3 rO u RESIDENTIAL COMMERCIAL OTHER
OWNERS �t,gyp /� HAZARDOUS FIRE AREA
NAME-1' K L_OIG_EAV�!)VI YES ❑ Ifyes—Iunderstandthata Class
roof assembly Is required.
t C _ r NO ❑ Initial I.C.B.O.
n M
ADDRESS 1`025 S � $K CAr3'I61J I[ EXISTING ROOF COVERING
PHONE (p — qm 5Z - NUMBER OF EXISTING COVERINGS
CONTRACTOR�'IS IC_�/
LCJ
NAME K.�tl L11S`�Ar�eG_ F]N(� I�( _ TO BE REMOVED TO BE RETAINED
ADDRESS r)
4PIE OF ROOF COVERING
clry a nP LAr _0L13 AMC.. S�� - EXISTING
PHONE (`KllbJ ls "O6�I BUILT-UP ROOF ❑
LICENSE �Z ❑
NUMBER T �� ASPHALT SHINGLESSi
LICENSED CONTRACTORS DECLARATION
hereby Daffirmivision
that I em licensed under Professions
of Chapter g(commencing calif Sectionand WOOD SHAKES
7000)of Dlvlalon 3 0l the Business and Proleeslone Code,and my license Is In full lona end
affect. ❑
_ WOOD SHINGLES Q
License Class Lic.Number
Data Contractor p NG OTHER(SPE(;IFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. `•
PA
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish, statement
anystructure,he is license Issuance,to the
visions
irequires the BUILT-UP ROOF
applicant for such permit to Ills a h,or re statement Ihet he is licensed to Its
pursuant al the l the 6! d QO (/'Bt_'lV���f^Bi►`Gp
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Dlvlalon 3 of the ,�y,,
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHll`% )E3,:L
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ensation,will do WOOD SHAKES
e civil penalty of not more than five hundred dollars($500).): UrCM r/�
01.as owner of the property,or my employees with wages ea their sole comp '
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
slonsCode:The Contractor's License Law does not apply toanowner ofproperty who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that El
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) El
build or Improve for purpose of sale.).
01,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractor's 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)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
0 I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUIIdindil.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
-permu is Ieeaad. y1 J''n/ IY///%/t
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
t bor Code,for the performance of the work tar which this permit is Issued.My Workers
Compensation Insuranceu!ranncce carrier and Policy number are: Total
Carrier v 1�1 G L.QM r• Policy No. L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Q❑
(This section need not be completed It the permit Is for one hundred dollars($100)or leas.)
I certify that in the performance of the work for which this permit Is Issued,I shell not am toy
any person In any manner so as to become cu ct to a Wo kers'cold naetlon Laws of Cell• All roofs shall be inspected prior to any roofing material being
arnia' - C installed. If a roof is installed without first obtaining an
Date 2_ J y I� Appucam +� inspection,i agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply
subject to the Workers'Compensation previsions of the Labor Code,you must forthwith comply PP p with all non point
with such provisions or this permit ehal0be deemed 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 state laws relating to building construction Al roof overings to be class°C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
(We)spreesand
save,Indemnify and keep harmless nyythe City ai Cupertino Ci against Ilabllltlae, - • /� 1/ T
judgments,casts end expenses which they In any way accrue against seltl Clry In consequence
of the granting of this permit, IGNATURE 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
J
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.
• b. 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: PV M C, VlC�
ADDRESS: I CDg ZS ST C yr,A)g CA N'Md )
RE-ROOFING COMPNAY NAME: AWNCF
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
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