R-6605 APPLICATION FOR CITY of cuPERTwo
NUMBER PERMrr
R� 6605
INSPECTION DIVISION PERM IT EXPIRATION
REROOF PERMIT ' (408)777-3228 - PERM IT EXPIRES IF WORK IS NOT STARTED'
'
WITHIN 18OF
DAYS PERMIT ISSUANCE OR
N.
WI F DANS FROM CALLED INSPECTION.
BUILDING ADDRESS
ARESIDENTLAL—Lo—COMMERCIAL OTHER
OWNER's HAZARDOUS FIRE AREA
NAME
iYl?_ 814 &-404" `Es ❑ �° embl is �teaBwA
ADDRESS1� �7� '��'`'eAR ST �2s - - ' EXISTING ROOF COVERING
PHONE Z 15-3 — 790 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S {� _ '
NAME CvR4t eR s tore tl �;C/�. - TO BE REMOVED / TO BE RETAINED
ADDRESS / l TYPE OF ROOF COVERING
CITY B ZIP 14>L ✓N L�✓Jtfl%4 NO G2` " SANSo'ee,� - '
PHONA// \\ p 9 r2a EXISTING .
40i) ` BUILT-UP ROOF ❑
LICENSE l cf Zoe _ ASPHALT SHINGLES ❑
NUMBER l�J '
LICENSED CONTRACTORS DECLARATION ry
I hereby affirm that I am licensed under provisions of Chapter S(commamctlng with Section WOOD SHAKES CJ
7000)of Division 3 of the Business and Profeasions Code,and try license Is In full force and
effect.
WOOD SHINGLES ❑
License Clava � —� Lk.Number / y.'
Data Contractor CdR6f6T1aj �L4' 1?,pa � OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Busiress ere Prolaesbn°Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,alae requires the BUILT-UP ROOF -
applioent for such permit to file a signed statement that he Ie kcensecl pursuant to the provisions
• of Me Contractors Ucerm Law(Chapter B(corn'nendng with Section 7000)of DivWlon 3 of the
Business and Prefesalme Code)or that he Is exempt therefrom antl uro basis for the alleged ASPHALT SHINGLES
exemption.Arty volabon of Section 7031.5 by any applicant for a permit subjects the epplkant to
a civil penalty of not more than five hundred dollars(5500).):
❑I,Its owner of the property,or my employees with wages as Mea ads compenandon,will tlo WMERI
Me wwk,and Me structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contradore License Law does not appy to an owner of property who Iwllds or W
Improves thereon,and who class such work hinnest or through his own employees,provkled that ❑such Impmmmems are not Intended or offereofor sale.If,however,the bullding or ImprovementO ,ggg ❑Is said within one year of completion,the owner-builder will have the ourdm of proving Mat he ditlnot build or Improve for purpose of sale.).D 1,as owner of the property,am exclusively contracling with Iioensed contractors to construct
the proles(sec.7044,Buareas and Professions Code:The Contractors Lkrense Law does not PEPORTapply to an owner of property who bulge or to rovws thereon.antl who contracts for suM projects with a contractor(°)licensed pursuant to Me Contractors Ucenee Lew. - PSPECS.
❑I am exempt under Sec. - ,B 8 P.C.lar this reason
owner Date"
WORKER'S COMPENSATION DECLARATIpJ APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: riff�.k
as provided iidedd t1 ham o by Section 37M of the Labord will malmalri a Certificate lCode�,fort to asi for he performance of Mem for wh�khtth Building ��'-lJ,-��—•
permit is Issued. O
lal'fieve and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
-the Labor Code,for the pedormerne of the work for which this permit Is Issued.My Worlbre l' r
Comwnsa0onlnaur°nce terrier ere Pdicy number are: X11 �7 9 r�Up Total
Carrier s{A�£ Fu of Policy No. IyyU9� PERMIT AUTHORIZATION DATE '
- CERTIFICATEOFEXEMPTION FROMWORKERS'
COMPENSATION INSURANCE N.C11 I u(
Yl..
(This vecdcn need not be completed b the permit le for one hundretl dollars(5100)ar bee.)
I comity that In the performance of the work for which this penrtlt Is Issued,1 Mall not emply
any person In any roamer w as to became subiect to the Workers'Campenastlon Lawe O Calk All roof.^.shall be inspected prior to any roofing material being
torsi°. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCAffT: It,after making this Certificate of Exemption,you should become Applicant understands and will Comply with all non point
subject to the Workers'Compensation pprovislons of the Labor Code,you must forthwith compy,
with such provision or this parmb shal7be deemed revoked. source regulations.
I certly that I have read this eppllcellon and state that the above Infomnadon Is correct I agree
to comply with all ply and county ordinances and state laws relating to building eonetnx:tlm,and All roof coverings to be class"C"or better.
hereby authorize repreasnthiNes of this city to enter upon Me abom-mentloned property M In //11
(We)agree to aave,expenses
and keep h any
w as the City of Cupertino eg°Icon sique ce �,](/(�(Q `r
oftlpmart°,costs eM permit. which may In any way accrue against sed Cly In caneequerwe
of the grennng assts perm", 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 ACCESSTO 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 1,21 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 %<" 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. tt1�
HOMEOWNER'S NAME: R. Sk e 1n4,-1
ADDRESS: 1977 ,, Arms Anio- . (0ee
RE-ROOFING COMPNAY NAME: CO e H-e4 s Tb,, e I�oJF,t
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof%winword