R-6600 PERMIT .Fi- 660
APPLICATION FOR CITY of CUPERTwo NUMBER
INSPECTION DIVISION PERMITEXPIRATI N
REROOF PERMIT, (408) 777-9228 PERMIT EXPIRES IF WORK IS NOT STARRED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ``\\
t�� .N RESIDENTIAL COMMERCIAL OTHER—
OWNER'S
THEROWNER'S ` HAZARDOUS
NAME S\y y�� W � VES ❑ Int yles�ndy isreq rte ClessA
` , �n � NO [� - Initial I.C.B.O.R
��,�� e� 10--_\\\elll�lllllllll �'f W EXISTING ROOF COVERING
ADDRESS p
PHONE O D — NUMBER OF EXISTING COVERINGS
CONTRACTO s -
—f Gc TO BE REMOVED TO BE RETAINED
NAME Lk7
ADDRESS TYPE OF ROOF COVERING
CITY 8ZIPEXISTING '
PHONE _ . BUILT-UP ROOF ❑.
LICENSE ❑
NL BER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby aHkm that em Business
licensed rel Pr fe sons of Chapter 9lc«ns eis M with Section WOOD SHAKES
7000)of Division 3 0l the Businasa entl Professions Cade,erre my license lain hM lone end
ansa. WOOD SHINGLES
License C m ` LJc.Number p. � �WOOD
El-
OTHER (S IFY)
Date Contractor Q r'
OWNER-BUILDER DECLARATION PROPOSED U
I hereby affirm that I em exempt from the Contractors License law for the following reason.
(Sec.7031.5.Business and Profession*Code: Any dry or county which requires a permit to
nstruct. 1IN
coafter,Improve,demolish,or, repair any evutture,prior to Its Issuance,also requires the. BUILTU 00�U 09199
pu�
applicant for such permit to file a signed statement that he P,Ilcensed Pru resent to the provisions J
of the Contractors Ucense Lew((Chapter 9(commenclnp with Section 7000)of Divblon 3 of the '
Business and Professions Code)or Pet he 4 exempt therefrom and the basis for the alleged ASPHA A$HINGLE$
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to oy
e civil ponetty,of not more than five hund,e!Sellers WOOD SHA El
the
as owner of the property,or my employees with wages as their Sole powerfu lm,will 00
the work,and the Structure is Trot Intended or offered for sale(Sec.7044,Business and Profen-
elan,Code:The Contractors License Law does not apply to an owner of property who builds or WOOD$HING LES
Improves thereon,am who does Such work himself or through his own employees,prwlded that ❑
Such Improvements are not Internal or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the Sudan of proving mat he tlld OTHER($PECIFY) `
not bWld«Improve for purpose of eels.).
❑I,as owner of the Property,am exclusively,co«mctin wHh licensed contractor,to construct
the project(Sec.7044,Business and Professions Cope:The Contractors Ucen,e Law dose net PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who W Ilia or Improves Marson,and who contracts for such protects
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. - ,B 8 P.C.for this lesson
owner oats
WORKER'S COMPENSATION DECIARAT10N APPLICATION DATE VALUATION PERMIT FEE
'
her
_'Mm
undo,penalty of perjury one of the following declaration: �7
ve entl will aft. In a CertlHcata of Consent to self-Insure for Worker's Compensation, Building , 1 7
lded for by 9ealon 3700 of the Labor Code,for the pe dormence of the work f«which this ,
permH Is Issued. I � 0
-11 have and wig melntaln Workers Compensation Insurence,as required by Section 3700 of - 1 $eISmIC Q�y Q
the Labor Code,lar the pedormencollof the work for witlM Mie permit le Issued.My Workers Total 1,, V
Compensation Insurance carrier end Polley number are �
Carrier 'Policy N-01�4p��p" 1 1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit is for am hundred doffars($100)or lass.) �•— ^
1 certify get In Me performance of the work whk:h MIS permit Is issued,I shell not employ
arty M manner eo a,ro bepdms* ro the workers' mpareauen Lowe of Call. All roofs shall be inspected prior to any roofing material being
romla. - installed. If a roofjs installed without first obtaining an
Datel� Aupllcam' inspection,I agree to remove all new materials for inspection.
eubfec�t toEMeWorkers'CCoompeneatbn p Monis o�them"iab1epal u muya h WMp Applicant understands and will comply with all non point
with such provisions«live permit*hon be deemed revokes. SO rCe regulations.
I certify that I neva reed this appllcetlon and state that the above Inbrrtsibn le corns .l agrse.
to comply with all city and county ordinances and state laws relating to bulldIng consiruglon,entl A OOf'COVerin S 10 b@ Class or bettef.
hereby auModza repmeanetives of this city to enter upon the'above�merdoned property for In.
sowflon purpoea,.
(We)agree to save,Indemnity and keep harmless the City of st Cupertino C epelrnsl Ilebltluea
lad menta, g of and expanses wrkh may In arty way accrue against 9eltl Ctry n caneequernce
of tie grentlng of we permit. SIG MATUR q O PPLICAN DA E
PRE-INSPECTION: PLYWOOD: -PROGRE
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 3.
1. 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 fust obtaining an inspection, you will be required to remove
all new material down to the shearing 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:
ADDRESS: 'JOnn3__ ��
RE-ROOFING COMPANY NAME: 10Ak� F
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-mof/winword