R-6501 PERMIT R_ . 6501
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ISO DAYS FROM LAST CALLED INSPECTION.
•
BUILDING ADDRESS / �/
V r,U�PE L L �L A- RESIDEMIAL_p_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
DPiRRYL 5 KtiRR / / YES ❑ tlyd%w de(. .Uinta CI;=A
.. NAME u G rod assaMy k regWrit
NO l tr1ma1 LC.a.O.f
ADDRESS 12:011r NIA?'FaLi 1 LAU , C),k FM-n 114o• EXISTING ROOF COVERING
PHONEU.O- - I NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S ITO BE RETAINED
Lr �j Vv�,N� ' TO BE REMOVED
NAME 1`
ADDRESS 1 `( /'1. „ I M �L LOS �ATUSI IMI TYPE OF ROOF COVERING
CITY 8 ZIP l o UN'r^LK^�',�
%�- �27 ` EXISTING
PHONE 7 BUILT-UP ROOF ❑
LICENSE
NUMBER _ ASPHALT SHINGLES
❑
7 l
LICENSED CONTRACTORS DECLARATION '
I hereby affirm that I em licensed under provlekxda of Chapter B(commencing with Section WOOD SHAKES
7000)of DMslon 3 of the Business and Professions Code,and my llcanme Is In full force and -
effect. /
�aaCpg � -12-11511 oI SHINGLESWOOD
❑cone Close 1 Lc. umber . .
Date P• �-30^00 Contractor�L QA011-IN(r OTHER(SP 11Fv)APR 2 8 1Ji i Il
OWTJER-BUILDER DECLARATION PROPOSED u L f
hereby affiml that I am exempt from the Contractor's ucenaa Law for the following reason.
(Sec.7031.5, Business and Proloselons Code: Arty city or county which requlr a permit t i p��
coarl after,Improve,demolish,or repair any structure,ppror to he Issuance,ala idlest BUILT-UP RQCII`/—�__❑__'
eppllcent for such permit to file a signed eletement that he b IlceMed pursuant loth rovlel 9 -
. of the Contractor's Ucense Law(Chapter B(commenclng with Section 7000)of DM 3 e
bne
Business entl ProfeaeCode)or that he le exempt Merefrom and the a the egad ASPHALT SHINGLES ❑
exemption.Any vloletion of Sectlon 7031.5 by any applicant for a permit au applicant to
e dull penalty of rot more than five hundred ddlere(E5Wp): WOOD SHAKES
❑1,m owner of the property,or my employees whin wegee se their We c enna n,wllldo ❑
dw work,eM the structure 4bbWulldsor
ndetl or offeretl for ea (Sec.7 Buel m eM Proles-
ekxuCotl:ndthe tructutorsLewtloeenoteppyto orrtor rope who
Law
WOOD SHINGLES
Improves thereon,entl who dwork Itimself or Ill nem rooked that ❑
such Improvements are rot mr offered I sa .II,h rrg or mprovemenl 11.v �, �,/
Is said within one year of comhe owner.builds IN neve tin burden atproying that he tlk OTHER(SPECIFY) Yvl pok 14 Tr
not build or Improve for purpola.). C`❑t,ee Owner of the propexcluerely nimdln hit lkenaetlwnbedore toconstructO✓+� IvMe project(Sect.7044,BuslnProfenal Cotle1The nincfor'3 License Low does not PROVIDE I.C.B.O.REPORT NO.
appy to en Omer of property dsor lm oven Meraon,e whocontmcleforedproleds
whin a conbadorta)loensetl to ih ontredore tics Lew.
am exempt under sec ,B S P.C.for Miareenon _ PROVIDE MFGR.INSTALLATION SPECS.
owner Dote APPLICATION DATE VALUATION PERMIT FEE
WORKER'SC PENSATION DECLARATION'
I hereby affirm under penehy of parluryof the following declaration:
❑I have and win maintain a Cerdllcule a mto"114nsurs for Workers Compeneellon, Building
u prWded for by Section 3700 of the Labor Code,for the performance of Me wok for which this 'I
will Is issued. � l
e sadmli maintain Wool ees Compenaetbn Ins mR ,ea requirbtl by Section 3700Ot ,OOD. —• Seismic
t havCode,for the performance of the wok for which We permit Is Issued.My Workers
-Compon Policy number ere: Total /
Carrier �lfJb Polity No" lt lob'b-`lg PERMIT AUTHORIZATION DATE
CERTIFICATE EN ATIONI SURANMNORKER5 --s
,COMPENSATION If IN ION INSUfor am N.CL]
(TTW satlfon need not be completed If Ura permit k for one huntlratl dotlars($100)or IeesJ
I certify Met In Me perbrmarwe d the wok for which MU parmlt le fill I BIWI rotarq loy
eery Person In any manner was to became aubled to the Workers'Compenaetbn Lowe d Cao- All roofs shall be inspected prior to any roofing material being
Whitt. installed. If a roof is installed without first obtaining an
Date Applicant .inspection,I agree to remove all new materials for inspection.
aublecctlto theWorks-
f Compefnsellonafter np ovnlelonls oleMelicate Lebo Code'�you m must forl you r'M.mloh«orroly Applicant understands and will comply with all non point
with such prwalons O this permit ehelObe deemed revoked. source regulations.
I tartly Met I have read this applfoetion and state Met the above Information le coned. e
to comply wIM all city and county ordinances and eters lows reletlnp to bulling const and All roof coverin s to be class r better.
hereby authorize repreeemuldvee of Mle dry to enter upon the above-menkrund pro ty for In-
epect e)87Wlxjrptoe.
(We)agree a cave,Indemnexpenses
and leap harmless cc Gry, ai Cupemro y In n Ilaquon o
IudpmenW,coati and expenses which may In any way sane epelnet nam Cary In naequence SIG RE OF APPLICANT DATE
of the aurin of Mls 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.
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 %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: tel} (UN�S�p �N11I
ADDRESS: 124 ipipk nl i D
RE-ROOFING COMPNAY NA
APPLICANT'S SIGNAT � L --
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof/winword