R-6590•
•
FFICE COPY
PERMIT R- 6590
APPLICATION FOR clTv of cuPERrINo. NUMBER
• 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
-
0.2 o f3 jr
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S
HAZARDOUS Fill AREA
�En_
YES ❑ H yes — I understand that a Class A '
NAME_ ll� �
roof assembly is regWred.
NO ❑ Inbal I.C.B.O. It
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS 1�106y. VC A4-�S
ADDRESS�
PHONE
-
CONTRACTOR'S
`
/. r t�},� ,%�rS
NAME W ,G/ Yl- / ,
TO BE REMOVED TO BE RETAINED
,N.0
TYPE OF ROOF COVERING
ADDRESS lSi�3
CITY B ZIP_ J(7/ /��yM ✓ `� Sl.h�
EXISTING
PHONE IlU if _ . 36,f 1f 0SI;4
BUILT-UP ROOF ❑
LICENSE
NUMBER p
ASPHALT SHI(yGL -
TTTJJJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAK
7000) of Division 3 of Iha Business and Probe ell Code, end my I ssu es la In ful bice and
effect
G
/ 7
WOOD SHING 0 2 LJ
License Cie G`o�7 Lic. Number
,JUN
% � L,
L OTHER (SPECT ) ❑
Date Con o -em«
OWNER -BUILDER DECLARATION
I h«eby alfl. that I em exempt from the Contractors license Ian for tiro allowing reason.
PROPOSED' By .
(Sec. 7031.5, Business end Professions Code: Any.ctty or county which requires a permit to
construct, after, Improve, tlemoiine, or repair any stmcturs, prior to Its Iseueroe, also requires the
BUILT-UP ROOF E]applicant
for such permit to Ills a signed statement that he le licensed pursuant to the provisions
of the Contractors acmes Lew (Chapter B (commencing wfth Section 7000) of Olvision 3 of tib
Business and Prolesmons Code) or met he Is exempt Merafrom ane the basis for the aftageA
A ALT SHINGLES
exemption. Any October, of Section 7031.5 by any applicant for a parted subl the appllcan
e dull penalty of not ore then five hundred dollars (5500).):
❑Lea owner eprothe five, or In empbyeeewfthMges00).): their Bole will oe
WOOD SHAKES
pe
the work, ark M fracture le not Intended or off ed for Bele ( .7044,Proles
eons Code:T Connector's License Law does apply to en nor of arty lids or
Improves the on, end who dove such M hlme I rough his em e, pr e l Met
WOOD SHINGLES ❑
such Imp anile ere nod Indentled Bred howeve tis Gill ftp Or Improvement
Ie eoldw none year ofcmplelbn, th Or- or burden of prosrq that he did
OTHER(SPECIFY) ❑
not cul r Improve tort par of sale.
❑I sowrrar of the prop ,em exci Fiery cting with licensed contractors to construct
Me pr 7044, ase antl Prof Mons sae: The Comrectore License law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owns r rty who bulcsor proses Merean, end who contracts breach projsde
with a eontrsator(a) meed pursuant to the Contractor's License Lew.
❑ 1 am exempt unyr sec. ,B a P. C. i« the reason
PROVIDE MFGR. INSTALLATION SPECS.
o«ner I - Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm un art penalty of perjury one of the fol neing dedeatcn:
❑ I hoer and wl8 maintain a Certificate of Consent to serineure for Workers Compensation,
Building
as provided for by Settlor, 3700 d the Labor Code, for the performance of the v for which Mb
permit Is issues.
q 0
�/I
�Theve and will the Perf WorkersCompensationfthekfor Insurance, as requires by Section 3700 s'J
the Lebon Case, for the Performance of the work for which Mle permit is leeuetl. My Workers
1
/
Seismic
q
8 0
Compensation I m carrier end Poky number are
Total'//2— 1 r
Cartier IYAT Posey No llAVQ .
PERMIT AUTHORIZATION
DATE
CERf1RCATE OF EXEMPTION FROM WORKERS'
r
COMPENSATION INSURANCE N.C.0
(This section need not be completed It the permit Is for one hundred dollars (51 ) or Iese.l
I certlty that In the performance of the work for which MIs permit Is Issued, I nod em
I_
nay Person person In arty manner so as to become subject to the Workers' 'sat Lowe of
All roofs shall bei inspected prior to any roofing material being
were
installed. If a roof is installed without first obtaining an
Data --�— A I
inspection, I agree to remove all new materials for inspection.
rImm
NOTICE TO APPUCANT:, If, eller maks ihCa bade of Exem on, you ahouhl become
Applicant understands and will comply with all non point
subject to the Workers' Compensation pr of the Labor Code, you must forthwith comply
with each provisions or this permit shall be deemed revoked.
source regulations.
I certify Mat I have read this application end stele Met Me above information Is cored I agree
to comply with all dry and county sternal and state leve relating to building consWction,are.
All roof Coverings to be classl or better.
hereby authorize representatives of this dry to enter upon the ateme-newhonea property for In.
'
specdlon'purposes. I.
(We) agree to cove, Indemnify and keep hermbss Me cry of Cupertino against IlabllMes,
in
-
SIGNATURE OF APPLICANT DATE
prtlpm ich may
ments, ete ane nswhich hwa
any y accrue against sac City In consequence
of the granting of this pemiL
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
FFICE COPY
• 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.
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.
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 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: ,A F
ADDRESS:
RE -ROOFING COMPANY NAME:,] / i
APPLICANT'S SIGNATURE:
J"�
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-rMMnword