99070020 '3 Co 2 — 1. o o gL70 10Dc20
APPLICATION FOR CITY of CUPERTINO NUMBER
T INSPECTION DIVISION
REROOF PERMIT (408)777-3228' . PERMIT EXPIRES IF WORKS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
)BUILDING ADDRESS
RESIDENTIALJK_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES 0 If yes—I_understand that a Class A
NAME `eY'-'�^•�1� roof assembly is mquired. -No ❑ Initial I.C.B.O.N
ADDRESS 't EXISTING ROOF COVERING .
PHONE
. —'417 NUMBER OF EXISTING COVERINGS Z
CONTRACa1}0R�'Sf
NAME ' 'ynLRl'/y/ q ' _ �+ TO BE REMOVED TO BE RETAINED f
ADDRESS / 9i/� 3 pt COVERINGTYPE QF ROOF
CITYB
EXISTING
PHON�lQ/ 6 `S `e 6 V - BUILT-UP ROOF
LICENSE
NUMBER L 40 A 6 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby eflnn that I em licensed under provisions of Chapter g(mmmenci with Section WOOD SHAKES — 1
7000)of DNWon 3 of the Business,and Professions Code,end my license b In Uforce and
offect. 6 WOOD SHINGLES fl
License Cb Llc.Number40 L�
Date contract« OTHER(SPECIFY) � nn
OWNER-"CI nROECLARATION PROPOSED Ju
hereby ,Bu that I am exempt from the s: Any city or coup Lew b the following a resew. '
(Sec.7031.5,,Impress site Professions ep Code: Arty dry or county which re,also a permit to
c«mbucCafter,u Improve,tlenwlbhigned any he=p1"to neabeuerce,eborequlresthe BUILT-UP ROOF By
app centforsuch permit to flaw aChnedr D(c*wntthathe bIkendo 70KO)pursuant n3ofons of the Contractors Dcenee Lew(Chapter h am empt tp wIM Section me basis of fort he 3 0l the
Bumps entl Prolotion f Cade)or Met he b exempt therefrom ane the jifuer the alleged to ASPHALT SHINGLES 7
exemption.Airy violation of than
I"]umr by any applicant t dor a pemlt subjects the applicant b
e dull penalty of nal more then INe hurMree dollero(55oo)J:
C]1,as owner of the property,«my empfoyeas with wages Me their sols compensation,will do WOOD SHAKES
Me work,and Me structure Is not Intended or offered for eels(Sec.7046,Business arta Proles-
elonB Cone: The Contractor's Ucense Lew does not apply to to owner of property who bullae or El
WOOD SHINGLES
Improves thereon,and who does such work himself or through his Own employees,provided that
such Improvements are not Intended or offered for use.If,however,the Wilding or Improvement
.Is sued!will one year of mmpledon,the owns-bolder will he"the burden of prong that he tlio OTHER(SPECIFY) ❑
rot build or Impmro far purpose of web.). r
❑1,as,owner of the property,am exclushay connecting with licensed contractors to construct
Me project(Sec.706,Business and Professions Code:The Contractors Ucense Law Was,not - PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who oullds or Improves thereon,and who connote for such projects
with a connections)licensed pursuant to the Contnctore License Lew.- PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Ow'terDB1e APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby allim under penalty of perjury one of the foliowin g declaration: -
❑1 haaa and wall maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as pnnddetl for by Section 37M of the Labor Coda,for the parlormence of the won,for which thio / p
permit Is Issued. 755$7W Of . Selsmlc
❑I have and will maintain Worker's f Me work
Insurance,en requiredsu Section oMe's
Me Lab«ll I for Me pertennance of Ne work r a which his pamll b 4euetl.My Workers /
Compeneetlo ha nc corder a Polley number are: 70181
Carrier 744!0n!4- PoldcyN571I 10006c5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit It ior orro hundred dollen($1 DD)«ism.)
I certiry,that In the performance cl the work for which this permit is Issued I shall roll empkxy
any person Ina manner w as to become subject to Workers'Compensation Laws of Cel- All roofs shall be inspected prior to any roofing material being
wmla. /J ,installed. If a roof is installed without first obtaining an
Date 7 Q Applicant r3• inspection,l agree to remove all new materials for inspection.
NOTICE TO APPUCAhIT: if,after melding this CerfillEate of Exemption,you shouio Ixxmme ,applicant understands and will comply with all non point
subject to the Workere'Compensation provisions of the Labor Cade,you a=forthwith connply,
with such provbiona or this permit shall be deemed revoked. source regulations.
I certlty Chet l have reed this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof.coverin obe Gass"6r better.,
ripo
hereby authorize repnea sentatNof this city up
to enter on era abovepe
-mentlonetl prorty for In. A• �
herallelf. 6
(We)agree to save.Indemnify and keep harmless Me City of Cupertino age]= Lai 4
of t�ha�prenncosts nd perrretcece which may in any way accrue against said City In consequence SIGNATURE APPLICANT • DATE
r
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 1,2, and J.
t. Pre-inspection or tear-off approval ; V
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 ''/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:
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof7winword