99100058 qq lb
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
VymffNDA DAYS PERMIT ISSUANCE OR
1W
tem DANSS FROM OF
CALLED INSPECTION.
BUILDING ADDRESS ,Q
LL EJB-E /? AVS+L
. RESIDENTIAL COMMERCIAL OTHER
OW ER'S \ HAZARDOUS FIRE AREA
mks.
/,�I A.� �] ✓`G� YES ❑ Ryes—Iunderstandthata ClassA
NAME mk �o iJ/'r /� � roof assembly Is required.
NO ❑ Initial I.C.B.O.1
ADDRESS __ J9 V I ge 6T 14116 , EXISTING ROOF COVERING
`
PHONE �5�-- 7'[ �� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S LI
C.. L UI-�'/ �y c; TO BE REMOVED TO BE RETAINED
NAME 4_J
ADDRESS �ooT lf�L L �1PE OF HQQE 01VERING
GITY&ZIP
EXISTING
UILT- �PHONE UP
OF
LICENSE 3d 9 7i ASPHA 'SH NGLTESl 1 1999
NUMBER
LICENSED CONTRACTORS DECI_IRXRON �.I�
I hereby affirm that I am licensed underdr
provisions of Chapter 9(commeng with Section WOOD SUSAKES
]000)of Dhislm 3 of the Buslress and Professions Code,and my license is in 10 Isn a and '
ane . WOOD SHINGLE
LJcense Class �L� 39 Uc.Number 3 6` •�'
_�/p� E /��Q OTHER(SPECIFY) ❑
Data contract« ,
OWNEis Co e: Ft Any
P /,/�zo
I hereby atlirtn that I em exempt from the Contractors Llcenae Law br the following reason. �/ /
(Sec.7031.5,Business and Proleeorone Code: Arty dry or carry iwhichssue requires a pertry
coralrut,ever,leproma,t complier.signed
n repair aro structure,prior to Ib lewerce,also r
ItheCapplicant for such peens m fila a(Chapter
r 9(commencing
em Met f t Ike ct
of the us a"areLicenseerl Lew(Chapter 9Isex ptwIM Sect' is /�
exempts antl violation of Code)or that he b exempt therefrom e t $ I ES G/y
exemption.Anyviolation
act oral Section hundred
ddany applicantfor a perm Ica a
e civil penalty of act more then Me huntlratl dollars($500).):
❑I,ae owner al the property,or my empbyas with capes es their soleco nsa ❑
the work,and the structure is not Intended or offered for sale(Sec.7(l Bu a es-
ebna Code:The Contactors License Law al not appy to an owner of pro y ❑
improves Merean,and who does such work himself or through his own empl
such improwrnents we nor afou ed or offered for Safe.If,however,the buildin proveme '
Is sold within one year of moria ion,Me owner-dhltler will have the burden of proN
not build or Improve for purpose of sale.).
❑I,asmneroln pm"rtyammcluslvelycmtectlngWthllcensed s
the project(Sec.71144,Business and Professions Cade:The Contractors no PROVIDE I.C.B.O.REPORT NO.
appy to an owner of prop"who Wide or Improves thereon,arta who can s projects
with a contrattode)licensed Pursuant to the Contactors License Law. PROVIDE MFGR.INSTALLATION SPECS.
-❑1 am exempt racer Sec. ,B 6 P.C.for MIs reason
owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
'I hereby Sturm racer panany of penury one of the fodowing deciareticn: ✓r �(�I
{novo Std will maintain a Certificate of Consent to sof-Insure f«Workers Compeneet on. (� q �I^/ Buildin ilU I6
es)jralvltled for by Secllon 3]OO of she Labor Code,for the performance of the work for which this (y y sv. �Y g
permit is lsaoed. / T �lJ l
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is issued.My Workers Total ` •�
Compensation Insurance censer and Polity number are:
Cartier S5 / ' Fyn/I� Pat No.a>'S 2)Z- y/` PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C[j
(This mouton need Trot be completed If the permit IS for one hundred dmlera($100)or baa.) J(O` ✓1N7� �G r
I carry Met In the performance of the work f«which MIs permit is Issued,I shell not wi lny /7
any person In any manna so as to become subject to the workers;Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
Iamla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.after making this Cerinfcate N Exemption,you should become Applicant understands and will Com with all non 0101
subject to the Workers'Coepeastation provisions of Me Labor Code,you meet forthwith campy pP comply P
with such provisions or INS Permit Mall be deemed revoked. source regulations.
I"diy that I have read Mie application and state Met the above Information Is correct.I agree
to comply with all city end county ordinances and state laws relating to bullding cwtua- ibn,and All roof coverings to C ss"C'or better.
hereby will representatives of Ihis city to enter upon the above-mentioned property,for In.
$who.purposes. -
(We)agree to save,Indemnify and keep harmless tha City of Cupanlno agslriet IlabIINee,
Iucigmw.,casts and expenses which may In any way accrue against said Clry In consequence G lATUR F APPLICANT,/ AT
of the grenurq 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 J.
t. 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 ply-wood 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.
HOMEOWNER'S NAME: /Y/,QS. G En/ Ey i Z5- rl C
ADDRESS: /3'Ie E7
RE-ROOFING COMPNAY NAME: A,4,P— l�ooj iAlly
APPLICANT'S SIGNATURE: iy /�X�—�--
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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