R 5830 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5830
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,
BUILDING ADDRESS
10-M S 4\J,I RESIDENTIAL--/-4COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
-T OWL(:
YES ❑ If yes—I understand that a Class A
NAME_ J 1 M V V-F 1L(: �;.f roof assembly Is required.
^ NO Initial I.C.B.O.N
ADDRESS 10 340 5f-0V-F_S Hae.. An EXISTING ROOF COVERING
PHONE S'Z- ZI S NUMBER OF EXISTING COVERINGS
CONTRACTOR'S IZ
NAME Q �- C�Ofl, (bac
TO BE REMOVED_�TO BE RETAINED
0 C A-
TY a z P l 3gdS VA n cl e( �Au TYPE OF ROOF COVERING
EXISTING
PHONE ��C1 — 3 3 Z BUILT-UP ROOF ❑
LICENSE
NUMBER ss— ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em Business
licensed antler Professions
ions of Chapter y(commencing with Section WOOD SHAKES
]000)of Division 3 0l the Business entl Profeeelone Coda,and my license Is In lull force and
WOOD SHINGLES ❑
License Class ✓�_ Lic.Number
( Data Contractor R�Y�L / ¢_ OTHER(SPECIFY) ®
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason. ^ zx, ^f1n'�aOfy
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to A z1Y
construct,enter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
. of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the 01" UUrtN 1 iftiG
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($501
❑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 Profes-
sions Code:The Contractor's 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 sale.ll,however,the bul[ding or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) E]not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor'.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 contactor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,8 6 P.C.far 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:
❑I have and w111 maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is Issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of QQ Seiamlo
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's i /L
Camps n IlonlnewencecarrierandPolicy umberare: ([ .mss Total
canter V s Policy No. �Z&2.7�a PE AUTHORIZATI DATE
in CERTIFICATE OF EXEMPT FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars(5700)or less.)
I certify that in the performance of the work for which this permit Is Issued,I.,hall not employ
any person In any manner so as to become aublad t or am Com nsatlan Law.of can- All roofs all be inspected prior to any roofing material being
formal inst d. If a roof is installed without first obtainin an
�- obtaining
'an
� 2� npp;;cam � inspection,I agree to remove all new materials for inspection.
J� NOTICE TO APPLICANT: It,atter makin i.Certlncv of Exempt n,you should become Applicant understands and will cold
subject to the Workers'Compensation pre one of the bar Code,you must forthwith comply PP ply with all non point
with such provisions or,his permitshall ad mod rev ed. source regulations.
I certify ihell have reatl,hla eppllceil end dare that the above Information Is correct.I agree
to comply with all city and county ordinances an III state laws relating to building construction,and Airroof verings to be class„C"Or better.
hereby authorize representatives of this city to enter upon the above-montloned property for In-
spection purposes. `' / a3�8
(We)agree to save.Indemnity and keep harmless the City of Cupertino against Ilab111tlee,
• jutlgmen,s,costa end expanses which may In any way accrue against said City in consequence S A URE AP LCA D E
of rhe 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-rooting 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: i✓vl I� I/� weir„
ADDRESS: 10 3 qC7 54n0 Les 4Le•
K.
RE-ROOFING COMPNAY NAME: b LLJ6 /nl
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re•roo0winword