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R-6666 PERMIT R- 6666 -] . APPLICATION FOR CITY of CUPERTINo NUMBER INSPECTION DIVISION •PERMIT EXPIRATION REROOF PERMIT (408)777-3228 . PERMIT EXPIRES IF WORK IS NOT STARTED WITHINF DAYS PERMIT ISSUANCE OR WI DANSSFROM LAST CALLED INSPECTION. BUILDING ADDD�RRESS—/f//� (� �D (J-/.`k-� ' ` ( L� RESIDENTIAL COMMERCIAL OTHER OwNER��Sff HAZARDOUS FIRE AREA tiw�0 _ VES ❑ Myas-.understand that a Class NAME— '' _`� U �-�J root asserndy is required. I NO El Initial I.C.B.O.B ADDRESS-2:0l,f K l 11 P/5 I(t Y XV - !oS CA r0S EXISTING ROOF COVERING PHON (/Oft ^O 3 30 NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAMEyo,)-r ADDRESSTYPE PE OF ROOF COVERING CITYd P "'y rtn.\ w,n4 .. . 's.ok•g.�/ - EXISTING PHONE C08') 7$-O33C3 BUILT-UP ROOF Q . LICENSE ' NUMBER l O ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a(commencing wim Section WOOD SHAKES 70DO)of DMelon 3 of MeBusiness and Professions Cade,and my license Is In full face and - effect. - 37 License Class Lic.Number �2(© WOOD SHINGLES7rE:l DateContractor t e Q OTHER(SPECIFY) OWNER'BUILDER DECLARATION PROPOSED 819991 hereby affirm that I am exempt from the Contractors License Law for the following reason.(Sec.7031.5,Business entl Prufessloos Cotle: Any city or county which requires a permit toconstruct,alter,Improve, structure,he ispror Ice its lsauance,talsoom requires BUILTUP RCCF' applicant for such permit to flaw a elhapt statement that he leh Sa�ed pumuent to me provolone of ma ss,and Ucense Law(Chapter B Is ex endng wlef Section 7000)of for ionthe 3of lethe eve ptio entl Violation of Code)or Net he le exempt therefrom and the bees a the applicant to ASPHALT SHINGLES By exemption_AnyViolationo t more of than five 7031.5 by erry applicant($50,).for a permit subjects the applicant to e clivi penehy of not more then five hundred dollars(5500).8 ❑1,as owner of the property,or my employees whh wages as their ads compensation,will do WOOD SHAKES ❑ the work,and the structure a net Intended or offered for sale(Sec.7044,Business and Profen- . Mons Code:The Contractors I-Icense Lew does not appy to an owner of property who bullae« WOOD SHINGLES Improves eon,and who does such work himself or through hs own employees,probldetl .that ❑ such Improvements are not Intended or offered for sale.If,however,the building or Improvement Is sold within one year of completion,the owner:bulklar will have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of ealeJ., 01,as owner of the property,am exclusively contrectin with licensed contractors to construct the prgea.(Sec.7oat,Buelneee entl Proleeelona CodeaOhe Contractors ucanee Lew does not PROVIDE I.C.B.O.REPORT NO. ap rio en owner of property who builds orlmpravaa thereon,and who contracts for such proocts An a contractor(s)licensed pursuant to the contractor's Joan"Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. a a P C.for moa reason OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE ' I hereby afOrm under penalty of penury one of the following decorerer: /p7 ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building set provltled for by Section 3700 of the Labor Code,for the performance of the work for which the .. ' . 5� Pe It s saved. / 1{�,�f�D ' �f hexb entl wool maintain Workers Compensator,work for I hick this as required by Section Workers d q,J SEISMIC Me bor Code,for the pedormenca of to work for which this permit o leauetl.My Wakere -�f / Com neat I`�aurerceParrsraMP.ollic number are: ,...rA Q • / Total .Carrier L�� 7wr)U �✓ mss•.. Polley No.�r- 3 w o� l PE UTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM W ORKERS' COMPENSATION INSURANCE N.CQ (This section need not be completed If the permit Is for one hundred dollars($100)or lase.) 7-//,� /fol' ale I cerilly that In the performance of the wfor which ole permit Is leeued,I shell not emqqoy (( any person In airy manner so as to become subject to me Workers'Compensation Lowe of Cell- All roofs s acted prior to any roofing material being forma' installe If a roof is installed without first obtaining an Data Applicant inspSo on,I agree to remove all new materials for inspection. NOTICE TO APPUCANT: d,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provobns of the Labor Code,you must forthwith comply .with such pmvleions or this permit shell be deemed revoked. Source regulations. . I tartly mat l have read this application and state that the above Information is coned.I agree p' h ren ly withRodror all rcItyes and aunty ordinances this cea ho a Mete Is"poo relabove-montion dna loamy and All r rings t be C18SS"C"or better. hereby authorize repwsentatNea of this cloy to enter upon Me ebovamentloned property for In- - (We)agree to save;expenses w and keep harmless the City of Cupertlrw egelnet I quures, ofjudiftnembigran coats ark expellees which may In any way accrue against Bald City In consequence of the granting permit. 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 ACCESSTO ROOF SHALL BE-PROVIDED FOR INSPECTION ' OFFICE COPY ' I• CITY OF CUPERT 1i O - BUILDING DEPARTMEVT 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 ail 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: G2 w v . 521 CQ S ADDRESS: �� l9 y SJR,(-s 1 ^A V. f oS orcTOS GP , �CSQ RE-ROOFING COMPNAY NAME: �1;:>"� se=Cso v�g APPLICANT'S SIGNATURE: ( _ CITY OF CUPERTINO BUILDING DEPARTMENT Re-rooUwinword