R-6630 PERMIT R_ 6630
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPiRATION
REROOF PERMIT
( �7]]-3ZZB PERMR EXPIRES IF WORK IS NOT STARTED
WRHIN IMPS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
9 �QN� , RESIDENTIAL�COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/ YES ❑ If yes-I uncienstand that a Class A
NAME roof assembly Is required.
NO Initial I.C.B.O.B
ADDRESS S L:Ns 0.Sg�o� EXISTING ROOF COVERING
PHONE Z QS NUMBER OF EXISTING COVERINGS Q��--
CONTRACTO 'S
NAME N TO BE REMOVED >�-C__ TO BE RETAINED
ADDRESS { k TYPE OF ROOF COVERING
CITY&ZIP ` 4
EXISTING
PHONE 2CO[ BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlsbro of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professional Code,and my license is In lull tome eM
ede4y' WOOD SHINGLES
C -"S� -7�� gam. ❑
Unnse Cleve Lk.Number
Date
g—�9 Comractor - OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION ED
I hereby eHlrm that I am exempt from the Contractor's License Law for the follmMg raeson.
(Sec.7031.5,Business and Profhrelans Code: Any city or county which requires a permit to
construct,alter,Inprove,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT U F�
applicant Mir each permit to Ills a signed salement Ihel he b Ilcenaetl pUr81190t to Ihe provisions
. of the Contractors License Law(Chapter B(commendrg with Section 7 )of DMsion 3 of e
Business,and Professions Code)or that he le exeopt Merafrom and th alis,for me ad ASPHA INGLES exemption.Any vblatbn of Section 7031.5 by arty applicantih
sant su Me 1 to
a civil penalty of not more Ilan eve hundred culture 5500)
❑I,asownero heproperlyormyempbyaeswl gIscomponsstlon,wilcar WOOD A YN 18 1ggg
the work,and Ih WcWre le rat Intended offered 1 sa .7 Business and Profes-
sions Code:Th Contractors Ucense Lew not alp wner of property who bulds or w00 SH W GLES
Inprovee Cher ,entl who does such work el or,N uawn employees, rovlded that �Y
each Impr na ere not Inten tl or offer b. ,however,the building or Pmprovement
baulk lnf one year ofcanpoll ,the own -bull Il hexa the burden of proving that he did OTHER(SP
not build or
into
for pure a of e.).
❑1,as rcfthe pr rh am cluaively n"ctln with licensed contractors to construct
the project ans entl mfessions Code:�he Contractors License Lew dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner r rtywhobull or lmproes thereon,and whocontracla for such projects
with a conlrector(a) head purauantt he Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt un Sec. ,B 8 P.C.for this reason
°cone` .Data
IVORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm uncer penalty of perjury one of the lolkrMng federation: Q �
❑I have and will malmabn a Certificate of Consent b selblraure for Workers Compensation, �, l q Building 11 -7
as,provided for by Sedlon 37W of the Labor Code,for the performance of the work for which this ���///}}}���
permit is Issued. yj 7Ak � Seismic D
`71 have and w it maintain Workers Compeneeflon Insurer,ce;as required by Sectiarl 3700 of �(�.p
.the Labor Code,for the padonnance of the work for which this permll is Issued.My Workers p
CompenseI IIneurp`nc_e eller entl Polley tracer are: t� 933-99
7 pq �, 1�9 \ Total ////-Z-7-0-
Carrier
/ Q
Carrier _ `"'� ` `-^•^++� Pot4,yNo. /S To -133 { l PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ($1 DO)
o 7—
(this saclbn need not be completed if the permit is for one hundred dollars(5100)or tees.) (0:1
I artily that In the pedormence of the work for which I penal b issued,I shell not amp"
any parson In any manner so u to become sutbkrctA the Workers'Compensation Lowe of Cali. All roofs shall be inspected prior to any roofing material being
Mime. installed. If a roof is installed without first obtaining an
Date Zv -l� 9 Applicant .--�--- inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alar mating this Cedmcate of Exemption,you should become A I nt understands and will comply with all non int
subject to the Workers'Compensation provolone of the Labor Code,you must lorlhwlth comply ID P Y
with such proviebns or this permit shall be deemed revoked. S 9 r Ulation S.
I cenfly that I have read this applicetbn and state that the above Information Is correct I agree
to comply wlh all city and county ordinances and state ewe relating to building conebudbn,eM I TOOf c Verings a Gass' Or better.
hereby authorize representatives of this city to enter upon the aboye-mentioned property Mir In. Q
epeclbn Wrpaeee. l
(We)agree to ave.Indemnify and keep harmless aro CIly of Cupedlno ge Inst Iiabllties,
Ntlga gran cosh entl a rural. a wNch may In any way earue against veld Cllye in consequence SIGNATURE 0 APPLICANT DATE
W the granting of and formal.
'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
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.
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 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: L w
ADDRESS: 7 23 17 5 Ac)�
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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