R-6665 APPLICATION FOR CITY OF CUPERTINO '
NUMBER PERMIT
R- 66 6 5
INSPECTION DIVISION PERMIT EXPIRATIOP
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
O RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\ c \ YES ❑ 1 yes-I understand that a Glens A -
NAME 0:n MA N sia`\'�N/ M *,Uj �7�-Ni CAeS NO Elroofis required.Irvtial I.C.B.O.B
ADDRESS
7� 7 u� I L/2r S I(�v V• EXISTING ROOF COVERING
— Q IT- S. CIA. 3 0 /.
PHONE /! NUMBER OF EXISTING COVERINGS
CONTRACTOR
NAME :Oujr- SQ.0,,S Oris -\�-�(ry , q TO BE REMOVED�TO BE RETAINED
ADDRESSCITY&ZIP
TYPE OF ROOF COVERING
PHONE N&R BUILT-UP.ROOF
LICENSE
NUMBERLICE( ASPHALT SHINGLES ElNSEDOM"CTORS DECLARATION
I hereby affirm that I am Iicensed'under provlslons of Chapter S(commencing with Secdon WOOD SHAKES '
7000)of Division 3 of lite Business and Professions Code,and my,license is In lull force and
effect.
3 ^I LJ WOOD SHINGLES
Claw Numbe
❑
License Clo � Lic. r `So2
Date ?^ 7 Q�7 Cantreaor u^� SAGS a^1 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED - /1
I hereby ,Bu in that I am exempt from Me a: Any cry or roue Lew for the bifocal rowan. / -\,
(Sec.7031.6,Business eM ProbeNons Code: Airy city or county which requires a permit to PJUL,�r8
construct,after,Improve,demolish,or repair any structure,prior to Its Issuance,also requires Me BUILT-UP ROOF ❑applicant for such permit to Ills a signed statement Mat he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter g(commend with Seddon 7000)of Division 3 of the �(t(t9
Busneas entl Professions Code)or Chet he le exempt therefrom end the basis for the alleged ASPHALT SHINGLE$ 99
exemption.Any vbietlon of Section 7031.5 by any applicant for a permit subjects the applicant to
' a dull penalty of rot more than Bve hundred dollars($500).):
C]1,as,owner of the property,or my employees with wages as I We compensation,will do WOOD SHAKES ❑
Me wxxk,and Ne Structure Ie rot Intended or offered for eels(Sec:7044,Business and Proles- By
alone Code:The Contractors Ucenee Lew does rot appy to an owner of property who betide or WOOD SHINGLES
Improves thereon,and who does,such work himself or through No oven employees,provided that
such Improvements are not Intended or offered for eels.II,however,the Wilding or Improvement
Is Sold wimin one year of completion,the owner-bulkier will he"the burden of proving that he dict OTHER(SPECIFY) El
build or Improve for purpose of sate.).
❑1,as owner of Ne property,am exclusWaly contracting with licensed contractors to construct
Me project(Sec.7(J44,Business and Professions Code:The Contractors Ucense Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or Improves Maroon,and who convects for such projects -
with a contnctor(e)licensed pursuant to the Contractors Ucanee Law.
❑I em exempt under Sao. B a R.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the loll&Mng declaration:
I]I have entl"maintain a Certificate of Coneem to sall4neure for Workers Compensation, - Building
m provided for by Section 3700 of the Labor Cade,for the performance of the work for which this
permit b§lje9ssed. .1
Vave end will maintain Workers Compensation Insurance,as,mqulred by Section 37W of _` $el$mIC
the Labor Code,for the Performance of Me work for which this permit Is lensed.My WoMere
Compensation Irsurence center antl Policy number aro: Total
1
Carrier U t 1�Q :Cb V A Z'Q-g. POIllyNo,la 7C_ 31T 8000 9 pE THORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the peirnit Is for one hundred dollars($100)or lase.)
.I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner Se as,to became Subject to tit orus ,peneation l-aws of call. All r .;shall be inspected prior to any roofing material being
Ionia. Iailed. If a roof is installed without first obtaining an
Date L�—t Applicant r inspection,I agree to remove all new materials for inspection.
�no ke eeip�eothLaecdeoPNsubjtMe Wa compensation rbne dthe Labor Cy000u= f forthwithuld� Applicant understands and will comply with all non point
with sunt provisions or tole pemnft shalQoe deemed revoked. source regulations.
I certify that I have head Mie application end State that the above Information IS coned.I agree
to comply with all dry and county ordinances entl elate lave relating to building construction,end All roof a gs to class"C"or better.
hereby authorize representatives Of this city to enter upon Me above rent oned property for In-
spection purposes. Q
(We)agree to Save, Indemnity and keep harmose the City of Cupertino against Ilabililles, - 7-( �
judgments,costs and expenses which may In arty way accrue eganat sold City Inconsequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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 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 NA IE: w >1N�xxif . Serv� C1eS
ADDRESS: 727 �hry�rsr �l/ /n4 /riS C. CoS . G4 . 9So3G
RE-ROOFING COMPNAY NAME: Sec? -Son S 1�
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-r oYwinword