R-6664 y j
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER ,
6664
• INSPECTION DIVISION PERMITEXPiRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FRDM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
///14' A k YES ❑ II yes—I understand that a Class A
NAME J�xk,.wv vA 1'\'UVJ• &-E! LC'PS roof assembly is required.
4 A NO ❑ Initial LC.B.O.k
ADDRESS—2.2-7
/2-7 Qn:L 0 , 1 P.
PHONE aa�? --O NUMBER OF EXISTING COVERINGS
CONTRACT 'S [� G /+
le-.
NAME �x 1 l &_Q O'Ek' a _'t" ZA TO BE REMOVED_TO BE RETAINED
I
C( 1 T TYPE OF ROOF COVERING
ADDRESS
!b 1� FTo r�1 :•,-.L S` S';5—co_9.3% Z
( EXISTING
PHONE \ C>a� -=279 — 0i26 36 BUILT-UP ROOF - ❑
U
NUMBERMBER „1 �ZI ® ASPHALT SHINGLES. ❑
N
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provWons of Chapter B(cornowncing with Section WOOD SHAKES _
7000)of GvWon 3 of the Business and Professions Code,and mry Ilcenee Is In NII force and
oft ' _ WOOD SHINGLES
License Cla+i--n Lk.Number 'y��I O - - ❑
Date ;? �� �9 Contractor s�4$GrS OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED D
hereby .Bu that em exempt from the e: Any cry License Lew for the blbMnp reason.
• (Sec.7031.8,Blmprove end ProMor re Code: Arty dry or county which requires a permit to D
applicant
Lor such
prove,to
a sigedst rerryewcw he pdora lbbwaoco,totheequlreeths BUILT-UP ROOF ❑
epMe CO far each permit a Ills a signed Inst he Pe Ilcen do pursuant to the provof Me �, ����
OR the ConsrsIXors ucenss Law(Chapter g(rommenclnaa wlth Section 7000)of Division 3 0l Me 1/`-�-9.
• Buslneas and Professions Code)ar that he ts exempt Merstrom and the bels for the alleged ASPHALT SHINGLES
exemption.Any violation o1 Section 7031.5 by any applicant for a permit sublecb the applicant to
e dull penalty of not more than five hundred dollars(58W),I: WOOD SHAKES❑1,se owner of the property,or my empkryess with wages es their sole compensation,will do By El
the work,end the structure Is not Intended or offered for sets(Sac.7o//,Buelneu and Protes. 1
slons Code: The Contractor,License Law was not appy to an owner of property who Wilde or WOOD SHINGLES
Improves thereon,and who wee such work himself or through his own empoyeu,prodded that -
such Improvements are ere not Intended or Oared for Mile.If,however,the building or Improvement
is sold within one year of completion,the owner-balder will have Me burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of Mala.).
❑I,au;owner of the property,em exclusively wntrechwith licensed contractors to construct
Me project(Sec.7044,Business and Profession,Code:The Contractors LIcense Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who W I Itis or Improves Marson,and who contracts for such prolecte
with a contractor(,)licensed pursuant to the Contrectore License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
owrmr oars
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby etlrm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certltkmse of Consent to self4neure for Workers Compensation, lding
asprovideda Id for by Section 3700 of Me Labor Code,for the performance of the work for vdrkh this 't? 0
pemnllJa Issued.
I
and wool maintain Workers f the w satin Insurance this
tie required by Section orkers $eISR11C
the or Code,for Me performance of Me work for which shoe carinii b Iseuetl.My Workers O
compe7n,I seance tarrler entl71cy number ars: Total
Carrier ter • l�q v`O u A- 7tjC' _Policy No,uc3o.! p aoo 9 PERUTHORIZAT N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q �� -77
(his section need not be completed If Me permit Is for one hundred dollars It1oo)a IaseJ:
1 certify that In the performance of the work for whlcN this permit Is Issued, Mall rotertp toy
any person In any manner so u to bmcme subject to the Workers'Compenullon Lew,d CMF All roofs all be inspec rior to any roofing material being
tome. - install If a roof is installed without first obtaining an
Date Apptleentinsir tion,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this CerlMcate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compansssbn provisory of Me Labor Code,you must forthwith campy, pP P Y P
with such provisions or this permit shell be deemed revoked, sourceregulations.
I certify Mel I have rutl this application and Mete that Me above Information Is correct.I agree
to comply,with all city and county ordinances and state aws relating to Wilding comwNon.end All roof cove '7o b , ass"C"or better.
hereby authorize representatives of this dry,to turner upon the above-mansldned property lar In- (/ --
apectbnPurposes. _�
• Iwo)agree to save,Incerrnity and keep harmless Me City of Cupertino epeln,t Iladlitle,,
Jutlpmenta,web and expenses which may In arty way ecwe against Mild Gy n wraequerce
• of tFe onsming of tis permh StGNjqFyREOFAPPLICANT 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 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.
J. 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 ''/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: (, , rV M�v� SQ r o r cte S'
ADDRESS: 7a7 v., xv s i Apy . ( mss G�Tos C� . aso3o
RE-ROOFING COMPNAY NANIE: Fp,/ Seasmrns FCS
APPLICANT'S SIGNATURE: w 9
•
CITY OF CUPERTINO
BUILDING DEPARTMENT
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