R-6596 PERMIT R_. 6596;
APPLICATION FOR CITY OF CUPERTIKO . NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - t. . (408),-777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOFPERMIT ISSUANCE OR
180 DANS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS
�C�7C� y� •. RESIDENT AL V COMMERCIAL OTHER
—
OWNER'S HAZARDOUS FIRE AREA
{�.�II ,, o I- YES ❑ 11 yes-I untlarstend flat a Class A
NAME p e f Ck SS Lc W ej roof assembly is required. .,
' /, � � NO ❑ Mida - LC.B.0.9'
ADDRESS '01� L 1��`i` tr �in Sor\ (�XZ EXISTING ROOF COVERING
PHONE — •y —y NUMBER OF EXISTING COVERINGS
CONTRALTO 'S ,� 1 (�
NAME �S� G S i�(]U�F�.r\Sr - TO BE
((� REMOVED TO BE RETAINED
ADDRESS , I,� ,�C h fJSe TYPE OF ROOF COVERING
CITY&ZIP "ti
" EX
L� ISTING '
PHONE- 44DC, 1;-61 Ll 4LIOil BUILT-UP ROOF � '
LICENSE - - -
NUMBER �. �3(a ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm met I em licensed under provlsbns of Chapter a(commendrg with Semon WOOD SHAKES -
7000)of Division 3 of the Business and Professions Code,end my license Is In lull force and
affect-
- WOOD SHINGLES ElLicense Class — Uc.Number 3
Dab Oonlor IDY ill, OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for me blowing reason.
(Sec.7031.5,Business and Profeeslons Code: Any city or county which requlas a permit to
construct.after,Improve,demollsh,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
epPllcen[tar such perms to file signed statement that he le Ilcensetl Pursuant to the Provisions
of the Contractors License (Chapter 0(command rg with Section 7(00)of D leba 3 of the
Business and Profession tie)or that he Is exempt therefrom and the basis r the Mile
ASPHALT SHINGLES
exemption.Any viola Se-'r ]031.5 by any applicant loffiempploe
eco applicant to
e clWl perrehy of not a than"' hundred dollen($600).):
E]1,as owner of property,or my employe with waveeneat o WOOD SHAKES ❑
the work,and the rudure le not intended oro for eee and Pmlae-
aona Code: chiral License Law does ppty t Ty who bulks or WOOD SHINGLES
Improves the n,and who does work hams If rou s,proNtletl that ❑
such Impr ants ere not Inlentletl ofaretl 1 sale. ding or Improvement
Issod with one yearoicom tlon,th owner erwlllhavetheburtlenolprovingthethadid "OTHER(SPECIFY) ❑
not bulla or ove for our se of sale.
❑I,aa owner ma pj arty,r exclu ivery contracting with licensed contractors to construct
Me protect(Sec.7 Auelness and Pmfesslone Code:The Contractors Ucanse Lew does not " PROVIDE I.C.B.O.REPORT NO.
apply to an owner of chert,who bulks or Improves thereon,antl who contracts for such projects
with a contractor(s)Ii need pursuant to the Contractors ucmm Law. PROVIDE MFGR.IN$TALLATION SPECS.
❑1 am exempt un r Sec. ,B&P.C.for this reason
ownerDab APPLICATION DATE VALUATION PERMIT FEE
' WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penefty of penury one of the folowUg declaration:
❑1 have and will maintain a Certincate of Consent to self-Insure for WorkersCompensation, " I l� Building°
as prmi tar by Section 3700 of the Labor Code,or the performance of the work for which this
permit ped' _ I Seismic
th2-
ha've and will maintain Workers Compensation Insurance,as required by Section 3700 of
Me
Labor Code,for the performance of the work for which this permit is Issued.My Workers
CompensCat Insurance car^ler end Policy number ere: 0U —..aq _ Total
Center ✓164,e " Policy No. l]l PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This sectbn need not be completed n the permit H for we hundred dollars($100)or less.)
I ceNry.that In be performance of the work for which this permit I I tl; all
not emptoy
any person in any manner so as to become sub] tome workers'c p ilon Lawn of CeII- All roofs shall be inspected prior to any roofing material being
krma. installed. If a roof is installed without first obtaining an
Dab Aypdcan - inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If,after making this certificate of Exemption,you should become •Applicant understands and will comply with all non point
• subject to the Workers'Ca ensstbn provisions of the Labor Code,you must forthwith comply
with such provlsoos or thle permit shall be beametl rar o eft. source regulations.
I certify that I have read this eppllcatbn and elate that the above Information Is correct.I agree
to comply with all city and county ordinances and stab lawn raising to bulking conatmctkn,and All roof Coverings classG or better.
hereby authorize repreeental of Mils dry to enter upon the abov -nnmticned property for In-
eped agrPeaea.
(Wee))agree to save,expenses
antl keep harmless the City of Cupertino Ci against Ibbllnbs,
ofthe gran costs and expeneas which may In any way accrue against sold City In wneequance
of the granting of varmn, SIGNATURE OF APPLICANT - DATE -
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 CUPERTIN - 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 fmal 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 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 %d' per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports arerequired 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. I 1 \
HOMEOWNER'S NAME: /—� pe_. a SSeA bf rS
a
ADDRESS: 1010 `1/��C) 4NC&yvS o n
RE-ROOFING COMPANY NAME: o S 0� S �oC7
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof/winword