R-6568CJ
., PERMIT R_ 656 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPI TIN
REROOF PERMIT . (4)777-3228 PERMrr EXPIRES IF WORK IS NOT STARTED
Will 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS Z 9 ( t{.pIM(PQAr1l
1 �y GA"Ci MAJi
-
RESIDENnAL-Z COMMERCIAL- OTHER.
OWNER''SS
HAZARDOUS FIRE AREA
/ `T' /� ^Y�
Vl
YES ❑ .Ayes-Iuntlerstandtlata Clal
NAME `-'Al .AJ -U:) I �° , ( )., /-t5$OC ,
mol assembly "Is required.
NO Irtthal I.C.B.O. 8
ADDRESS 5/
EXISTING ROOF COVERING
//
6
NUMBER OF EXISTING COVERINGS 1 L,4 yeR-
PHONE — b
CONTR
pACTOR'
NAME LltNhI $SA-AXe- IAiG LSO, �C,
TO BE REMOVED TO BE RETAINED
ADDRESS
L 6� �i5�z5
CfTY nP 2.2A Z f Ik)� LfJ Ave-
TYPE OF ROOF COVERING
EXISTING
" 6Cla
PHONE yO8 444IR oS
BUILT-UP ROOF ❑
LICENSE
NUMBER SSq 3316. EKP 3/3)/01 �
/ (
ASPHALT SHINGLES ❑
DCCONTRACTORS DECLARATION
hereby affirm that am licensed antler provisions of Chapter (come8col Section
WOOD SHAKES -
7000) of DMebn 3 of the Business and Professions Cade, end my licence
license 1
e le In In lull force and
effect.
c 3 9 � SncI 3
WOOD SHINGLES. ❑
Llcerma Coes LbNumber
OTHER (SPECIFY) El
CanaaclIX
OWNER -BUILDER DECLARATION
PROPOSED
hereby affirm that exempt from the License Law for the reason.
(Sec. 7031.5, an e: Any City viresfollowing
Cade: Any dry or county which requires a permit to
entl Profedemolish,
consirud, after, Improve, tlanollM, or repair any structure, prior to 11e Issuance, also requlroa he
r, mime or rep
BUILT-UP ROOF El
lar such permit to file a signed statement that he Ie Ikxineed pursuenl to the provblons
of the Contractors License LewChapter B (commencing with Section 7000) of Dlvlston 3 of the
Business and Professions Codes or that he is exempt therefrom and the basks for the alleged
ASPHALT SHINGLES
exemption. Any oblation of Section 7031.5 by any applicant for a permit subiscts the applilcant to
Uk�S
a civil poneny of not more roan the hundred callers (65110).):
the
WOOD SHAKES ❑
❑I, M owner of property, or my employees with wages as bull We comosarsalon, will do
(Z.
the workeels (S
, and the structure le not Intended or offered for ec. 7044, Business and Profim-
30 Y
sons Code: The Contractors License Law does not apply to an owner of property who bullds or
Improves hereon, and who does such work himsed or through he awn employees, provided that
WOOD $ ES C.� W e E x
❑"FAUSUA89
such Improvements are not Intended or offered for sale. If, however, the bUllding or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proNng that he did
OTHER
not bulb or Improve for purpose of eab.).
❑I, as owner of the property, am exduslvety contracting with licensetl contractors to constructZ�
project (Sec.70", Business and Profemlons Cade: The Contractors License Lew doss rot
Othe
PROVID Oapply
to en owner of property who bulIcs a Improves thereon, and who contracts for such projectswith a contractors) licened Pursuant to the Contractors Ucenee Law.S.
I Sec.
PROVID
❑ am exempt under B & P. C. for this reason
OmerDate
WORKER'$ COMPENSATION DECLARATIDECLARATIONTIO
APPLICATIO VALUATION
PERMIT F
TUCSt�Ay
Uldl
I hereby affirm under penalty of perjury one of he tolbwing declaration:
❑ I have and will maintain a CertNkate of Consent to eed4raure for Workers Compersation,
as pruvil for by Section 3700 o1 the Labor Code, for he performance of the work for which this—
px is Inlaid.
WAG
NA A
�I have and will maintain Warkere Compensation Insurance, as required by Section 3700 of
iM LEbor Code, for the performance of the woM for which this Is mail My Vja re
�/ /
permit
Compensti Insurance tamer and Policy number er EY I co
TO
��)�
CamerVir" 'Ll21VSURAakt bYNa.sK-r lyn4
PERMIT AUTHORIZATION
TE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE Nco
(This mcdon need not be completed 1 the permit Is for one hundred doikrs ($1 DD) or Iese.)
I certify that In the performance of the work lar which Ihls permn Is 1 sued shall of empty
arty person In an/ manner so as m become subje to the workers co pe 1 s f. alk
All roc hall be inspected prior to any roofing material being
fomla,
installed. If a roof is installed without first obtaining an
Datt 15,a Applicala
inspection, I agree to remove all new materials for inspection.
NDTIC APDL CANT: II, ansr ma is Certificate of Exemption, you Mould become
subject to the Workers' Compeneetlon ions of he Labor Code, you moat forthwith comply
Applicant understands and will comply with all non point
with such provalons or this permit stal deemed revoked.
source regulations. -
I certlty het I have reed this application and state that the above Information Is correct.I agree
to compy with all city end county ordinances and state laws relating to bullding conetmctlon,end
All r6. OVerings to beC y 'C' rbetter.
hereby authorize representatives of this city to enter upon the aboe-menlbned property for In-
apeWenagrposea.
(We) agree to Indemnity keep heroism the Clry Cupertino Inst Ilebllltlea,
s/a.� 99
save, and of a
dgme and which may in
Judgments,
t way Clryrn
coneng
NATURE OF APPLICANT - DATE
, any accrue agalrst Bald coneepueroe
the ol gamer
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
• 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.
I. 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 first obtaining an inspection, you will be required to remove
all new material down to the sheating and a building inspector will inspect all shearing 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. S -AAI 9
HOMEOWNER'S NAME: AR,Dt',,'J Ile, 2.2,4L H. AsSoc.
Pl��z.68- 68i�
ADDRESS: (C -u P)
RE -ROOFING COMPANY NAMI
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof/winword
NG.
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