R-6627 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6627 '.
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
`� �� �V ' I �• "� "` ! �V " RESIDEM7AL " COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA-
L} n yes—I undeista d that a Class A
NAME YES ❑ root esnemby Is required.
M •�1_ _/ '/ /� NO ❑ Initial - I.C.B.O.R
ADDRESS.�`�� S m��Rj/7J/YJ/'� 5 LIXI'y 1 (�i��7' EXISTING ROOF COVERING
PHONE ' D Q 7` NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S -
NAME' C./ N - TO BE REMOVED TO BE RETAINED
ADDRESS " OF ROOF COVERING
- CITY 3 ZIP -
'
I
PHONE �I�� 1111,1 -I L�BI�JI,7TP OF E]LICENSE
NUMBER lit 1V 1 OASPHAL INGLES ❑
LICENSED CONTRACTORS DECLARATION (t -
I hereby of inn that I am licensed under provisions of Chapter B(corn nendng w� t WOOD SH ES
7000)of Dlvlelon 3 of the Business entl Professions Code,entl my Ilcenum Is In lull rce e
affect. WOOD SHINGLES
ucanse Class Dc.Number
Date Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECIARATION - PROPOSED
I hereby affirm that I am exempt from the Contractors ucense Lew,for the following reason.
(Sec.7031.5,Business and Professions Code: Any dry or county which requires a permit to
canatruu,ester,Improve,demollM,or repair any structure,priorto lis Issuance,also requires the BUILT-UP ROOF
applicant far such permit to file a signed statement that he Is licensed punu,am to the pinwelon.
of the Contractor's License law,(Chapter B(commencing with Steffen 7000)of DMsion 3 of the
• Business and Professions Cade)or that he Is exempt therefrom aro Me basis for the alleged ASPHALT SHINGLES
exemption.Any Nolatlon of Section 7031.5 by any applicant for a permit wbiects the applicant to
e chAry of not more then We hundred!dollars
es owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the ork,end the structure Is not Intended«offered for sale(Sec.70",Business and Profes-
aoms Code:The Contractors License Law does not appy to an owner of property who builds or WOOD SHINGLES• ❑
Improve.thereon,and who does such work hirn"t or trough his own employees,prwlded that
such Improvements are net Intended or offered for sale.If,however,to building«Improvement
is
sold within one year of completion,the owmenlxJlder will have the burden of proving tet he did OTHER(SPECIFY) El
build«Improve ter purpose of sale.).
❑I,as owner of the property,am exdusivey,contracting with licensed conincron to construct.the protect(Sec.7041,Bu ineee end rafessons ode:The Contractors License Lew does mat PROVIDE I.C.B.O.REPORT NO.
apply,to eno ae Iprop wno foul pl pro a arses,erg who contracts for such protects
witem rt�aogs nce dpunua oma nth ors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 exempt nd x. ,B 8 P.C.for this reason
owner Dero APPLICATION DATE VALUATION PERMIT FEE
-
I
ENSA DECLARATION
I herat rm under penally of perjury one of the following declaration: -
❑I he t will melntaln a Cartlllcate of Consent to sakinsure for Workers Compe antlon, Building/2
din
as provided for by Section 37M of the labor Cade,for the performance of the work for which tIs g
permit Is Issued. C)
F7I have entl will melman Warkars Insurance,as Insuranas required by Section 3700 of 1 Seismic y
the Labor Code,for to performance of the work for which brie permit Is Issued.My Worker's "27` 3
S
Compensation Insurance Cartier and Policy number are: Total
Cartier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(Tide section on need net de completed to permit Is for one hundred dollen(5100)«lass.) (/
I earthy that N the ped«mence of the work for which this permit Is Issued,I Mall not employ
any person In any manner so u to become subject to the Workers'Compeneetlon Lawn of call- All roofs shall be inspected prior to any roofing material being
fornia' installed. If a roof is installed without first obtaining an
Date Applicant , inspection,I agree to remove all new materials for Inspection.
NOTICE a Ar*ers' ompansato prowa this of
Lab r Exemption,ustf rmould,"cc'o�9 Applicant understands and will comply with all non point
subject tote Workers'Com ,after king this C ins caber Code,
with such provIslons or this permit MelQbe deemed revoked. 51 regulations.
I cerdly that I have reed tie eppticafien and state tat the above Information le cartetl. agree
to rempty withauthorize
city and county orf this ces and.ter upon thelebc to ve-monficig ld prop rty for M' All roof V 10 f le � /�
hereby eutlp ose npreeenstives of this dry to enter upon to above-menibrptl property for m- 7-7) !///
ape(We)
purposes.
(Wel agree ro ease,indemnify and keep harmless me City of Cupertino against liabilities, /
judgments,costs art expenses which may In any way accrue against said City In consequence
• of the grentivg of this permit. A R OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSB ' 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.
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 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: / r/ /I
ADDRESS: `�! J St�J���ff>�/�/�J1� (� �A
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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