R-6589OFFICE COPY
PERMrr R -
6589
APPLICATION FOR CITY OF CUPERTwO NUMBER
' INSPECTION DIVISION PERMIT EXPIRATION
-REROOF PERMIT (408)7773228 PERMIT EXPIRES IF WORK IS NOT STARTED
.. WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDINGADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'eS
HAZARDOUS FIRE AREA
I D N
VES ❑ 11 yes — I ubtlerstaM toed a Close A
NAME 1'/1 \ V G
roof luaerrtbty is retprirtd.
f10 'EJIrYtlal LC.B.O.N
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11 g C TRO L 1-, 1'P
EXISTING ROOF COVERING
ADDRESS (o
PHONE - -
NUMBER OF EXISTING. COVERINGS
CONTRA 'S -
TO BE REMOVED TO BE RETAINED -
NAME
ADDRESS
S3� LOl9M �Nlt' L -.-la Sc}t1EX
TYPE OF ROOF COVERING
CITY a ZIP
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RJB?—
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PHONE �I� I17
BU CIJ�j PROOF .' ❑
Li
NUMBER !
ASLICENSEI ALWONaLOS1999
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licenced under provlaons of Chapter B (commencing with Section
W D SHAKES
]0001 of DMsom 3 of the Business and Profession Code, and my Ilcsrim Is In lull force and
effect. dy (,�
I
W - ❑
Ucenm Class � Lk. Number • "•
'51WVcoonecor
OTHER (SPECIFY) ❑
Date
OWNER -BUILDER DE LARATION
I hereby affirm that I em exempt from the Contractors Llcsnee w for the n neem..
PROPOSED
(Sec. 7031.5, Suelmse" Professions Code: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to lb issuance, also requires the
BUILT-UP ROOF ❑
applQnt for such permit to fife a signed statement that he Is licensed pursuant b fro provia0m;
of the Contractor's Ucense Lew (Chapter a (command with Section 7000) of Dlvislon 3 of the
Business and Professions Code) or Mat he Is exempt therefrom and the be for the alleged
ASPHALT SHINGLES ❑
examptlm. Any Nolatfon of Section 7031.5 by any applicant for a permit subl the apoll. to
a oMI penalty of not more than five hundred dollars (5500).):
d
WOOD SHAKES. ❑
❑1, n owner the Property, or my, empkryrae with wages es emm neatlon, wl
the work, and the structure Is rot Intended or are e'd forBela (Se ] as,
Nona Code: The Contractor's license Law tloee rot apply to er of erfy lifeor
WOOD SHINGLES ❑
Improves thereon, and o dose such work hlmsell or through e, provided that
such Imprbrsmenle er not Intentlatl m offeratl for e. 11, h r, ulldln r Improvement
Is withinora thaowner-WI haveth Nen that he dM
add of completion, rwill of provlrg
OTHER (SPECIFY) IfQQ''
not build m Imp or purpose of sale.).
'f-
❑1.as,owner the property, am exdusl ion with lie contractors to construct
the prolect(See ono, Business, and Profs on eContracto License Lawdoesnot
PROVIDE I.C.B.O. REPORT NO.
appyto en rof property who Iles or t er , and who contracts for audr projects
with a cont or(s) Ilceraed pumu tto the ntrnaore Ucenee Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am mpt u .' Sec. ,B 6 P. C. for this reeem
Ilk
OwnerDate
APPLICATION DATE
VALUATION
PERMIT FEE
C6PENSATtON
KER'S DECLARATION -
%
un peraity of por)ury orra o1 the following dedambon:
I heywimalnWn
❑ 1 Intern a Certificate of Consent to sell -Insure M Workers Compensetlon,
BUlldingl ��
as provctfon 3700 of the Labor Code, for the performance of the work for which this
Permit is
Ryy'�
ti
❑ I i malnWn Workers Camprmeadon Insurance, as, required by Section 3700 olthe
�2V /�,
S813mIC �L
Lathe performance of the work for which this permit le mued. My Workers
Compou nce carrier and Polley number are:
Total
Carrier PcllcyNo.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS*
^ Q
T
COMPENSATION INSURANCE N.GC]
(Title eectlon Treed rwt W completed tl the permit he for arra hundred dollars ($100) m IeeeJ
1 certify fat In the performance of the wonJL�r whfoh this permit Is Issued, 1 shall not employ
All roof^ shall be inspected prior to any roofing material being
any person In any mann r so as, to becomeb(u jeC ne worker m meatlm Lawn d Caw
fornia. -
installed. If a roof is installed without first obtaining an
Data Appllmrf
inspection, I agree to remove all new materials for inspection.
N01 CE fO APPLICANT: If, after makinfilIthim Certilicate of Exemption, you shmle become
Applicant understands and will comply with all non point
PP P Y P
subfect to fa Workers' Compensation pprovblons of the Labor Code, you must forthwith mmpiy
with such provisons o this permit shalgbe deemed revoked.
Source regulations.
I certlry, that I have read this epplicatbn and state that me above Information is correct. I agree
to comply with at city and county ordinances and state hives relating to Wilci mnstrucilon, and
roof cove to be classor better.
hereby aulf prize reffammathes of this dry to enter upon the above-mmtfoned property for b-
apedienrpcsea.
(We) agree to a Indemnify antl keep harmless the City o1 Cupertino Mequon
-lodgments,
d e
mere end expenses which may 1n any way ammr against aafo Clry In consequence
Ci y Inagainstcon a
'
GNATURE O A L ANT - DATE
of me prentlrg 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
CITY OF CUPERTINO - BUILDING DEPARTMENT
RE -ROOFING POLICY
Prior to permit issuance, you must agree to comply with U.B.C. standards and
Manufacturers specs on re -roofing.
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.
All types of roofs shall be inspected prior to any roof being installed.
In order to receive a final, you must complete steps 1,2, and 3
1. Pre -inspection or tear -off approval
2. In -progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
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 shearing and a building inspector will inspect all shearing at
that time.
IMPORTANT:
1. Flat roofs must have a''/1' 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:
ADDRESS:
RE -ROOFING COMPANY NAME:
APPLICANT'S SIGNATURE
. CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roogwinword
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