R-6248 PERMIT R_ 6248
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)T77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• '180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS JJ
RESIDENTIAL COMMERCIAL OTHER-
OWNER'S
THER
OWNER'S/ HAZARDOUS .
NAME `—�--e4 C4^& / —�/1'L.�Y� YES ❑ tl yes—I undercfaeq that a Class A
roof assembly"s required.
NO ❑ Initial LC.B.O.Y
ADDRESS— EXISTING ROOF COVERING
PHONE ZS —O S NUMBER OF EXISTING COVERINGS I
CONTRAC IS O
/ TO BE REMOVED---- TO BE RETAINED
NAME �_
ADDRESS
CITY&ZIPVC19,AL 11, I EXISTING
RHONE. 5Q.-S 3 T 3 9 BUILT-UP ROOF JUN 15 E 999 D
LICENSE /p' ❑
NUMBER `gyp 2 ASPHALT SHIN 3hES
LICENSED CONTRACTORS DECLARATION y
I hereby affirm that I em licensed under proVslons of Chapter 9(commencing with Section WOOD SHAKE
7000)of OJAson 3 of Ne Business al Professions Code,end my license 41n full force and r
effect MWOOD SHINGLES ElLicense Co. �,�M Uc.Number (1 u
Date -3af 4� Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARAA N PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the bwtr'r
(Sec.7031.5,Business and Professions Code: Any coy or aunty,which r Mas a par to
construct,after,Improve,demollah,or repair any structure,prior to lot Issuance, recut the BUILT-UP ROOF ❑
epplbant for each permit to Its a signed eottemam that he Is ticoneetl puauen felons
of Ne Contactors Ucerroe Lew Chapter B(comm end�with Sectio D 3 of the
' Business and Professions Codes or that he Is exempt therefrom an me ot for the alleged ASPHALT SHINGLES S
exemption.Any violation of Becton 7031.5 by any applicant fore je Ne applicant to r
e dull penalty of not more than five hundred dollars(550().):
❑I,uowner of Ne property,or my employees with wage, their ecompenatbn,well do WOOD SHAKES ❑
the work,and Bre structure Is not Intended or offer r cele( .7 ,Business and Proles-
ebneCode:TheContractorsL nee Lew does not to an r of property who builds or WOOD SHINGLES ❑
Improves thereon,and who tl work himself or h hie n empkryees,prwltlatl Net
each Improemente are rot Int ad or offered for sale h ,the building or Improvement
Its old wlNin one year olcom ibn,tlre ow WIWer neve the burden of proving Net he tlltl OTHER(SPECIFY] ❑
net Wild or Impro+a farW of sale.).
❑I,as owner of the ty,amexd Nay Who, ngmirllcensedantrectoatoconsbuct
the project(Ssc.70.4,Bu, tees entl P lose e:The Contractors Ucense Lew tical not PROVIDE I.C.B.O.REPORT NO.
apply Loon owner of prspy who bull sorlmprova areon,entl who contracts for such projects
with a contractors)Ilcen au to the Conti ore Ucense Lew.
❑I an,exempt under Sec. ,B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER' COMPENSATION DECLARATION
I hereby affirm under penalty of pe ry one of Ne follvMng tlecieatlm: "
❑1 have and will malntaln a Cortfiaot of Consent to set-Insure for Worker'B Cumpeneaton, Buildin
as pro,ided for by Section 3700 of the Labor Coca,for the performance of the work for which this g
polar"Imuetl. Seismic /,,? 0
end will the pert Workers Cape work ion Insurance,m required by Section 3700 of
N Labor Cads,for the performeroe of the work for which this permit W foauetl.My Workers � Q
ansatkn lneu orderer Policy number aa: TOta�
Gender � � Polly Nos 7/-??-��2 5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed H the Permit is for one hundred dollars(E1 W)or Ieae.) �v
I Fort that In the performance of the work for which this permit Is Issued I shall not emvTry
any person In any manner so as to become subject to the kora'Compensatlon Lawn of Cell- All roofs shall be inspected prior to any roofing material being
forma. I Installed. If a roof is installed without first obtaining an
Date L /A9 Appel inspection,I agree to remove all new materials for inspection.
IIOTIC TO APPLICANT. II,anon making
ovi this Cahebab 1 ode,you must
fonhaAd became Applicant understands and will comply with all non point
subject to the Workers'Compensation 11,after
rkinglona of the Lobar Code,
with such provlelons or this permit shell be deemed revoked, source regulations.
I certlfy that I has read this application and state Net the ebo.,e Information Is correct I agree
to comply with all city and county ondkunces and strata laws relating to building col and All roof Coverings be cls .4or better.
hereby authorize representatives of this dry to enter upon Na above-mentkxwd property for In-
ep(We)agrpaeee. // /q 9
(We)agree to save,indemnity ty end keep harmless Ne Clry of CuiderfinDst said Ci apn corn Iledllllee, • !o
jud menta,costs and expenses which they In any way ecwe against ad Clry In consequence SIGNATURE APPLICANT DATE
• of Igranting of 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
.OFFICE COPY ,
CITY OF CUPERTINO - BUILDING DEPARTMENT
i 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 J.
t. 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 %<" 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: �2Q/Lci
ADDRESS: l� /3 4
RE-ROOFING COMPNAY NAME: 1
APPLICANT'S SIGNATURE:
T
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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