R-6549 1
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6 5 4 9
- INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (407]7-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
1W DAYS FROM LAST CALLED INSPECTION.
/^I ' � -
0 I TO K 6�S /T Y RESIDENT AL -COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
C C- A A YES ❑ If yes-I urK1eBUM that a Class A
NAME roof assembly Is required.
NO ❑ Initial I.C.B.O.i
ADDRESS 0 - EXISTING ROOF COVERING
PHONE
U D 0 NUMBER OF EXISTING COVERINGS /
CONTRAC/7�� R'S }}/�
NAME /'y'N f ' ' " �� '?w F - S� �- TO BE REMOVED TO BE RETAINED
ADDRESS1 D 6o y �y�6y J. 9 S� Sc/ TYPE OF ROOF COVERING
CITY&ZIP 1
. EXISTING
PHONE 40S -AS--SI BUILT-UP ROOF ❑
LICENSE ,6 IS
r`� ASPHALT SHINGLES ElNUMBER J
LICENSED CONTRACTORS DECLARATION
- I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
]000)of Dlvlabn 3 of the Business and Professions Code,and my license a In full force and
effect.
WOODSHINGLES ElLicense Cli Lit.Number - FOP
(o - Z -9 9 �j /u OTHER(SPECIFY)
Data DBUIactof y O
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractors License Law tar the following r n.
(Sec.7031.5,Business and Profession,Code: Any city or county whl require-e p It to JUN
coratruc,after,improve,demolsh,or repair any structure,pdor to 1,l ,elser nee the BUILT--UP ROOF V,Y Ori1
applicant for each permit to Iib a signed statement that he is Ncenaetl passu o t rovlebns `� 'r1n
. of the an dors Ucense Lew(Chapter a Is ex a pt t with om jun] o an 3 al the 9g'
ex
Business exemption.
end Pre lafion f Code)or Met ala exempt therefrom e for the i a nt to ASPHALT SHIN I
exemption.Arty vldatbn of Sedlon]03 any
ant re t ,the applicant to
e dull pan-fry of net more Than five hu red dollen(5500.):
❑I,as owner of the property,or If as with wa elr cempereetwn,wndo WOOD SHAKES
Me w ,and the structure le not I nbed or offered for .704x,Business and Profes-
$I.$Code:The Contractor's L se Law dose ra y t owner of property who builds or WOOD SHINGLES ❑
Improves thereon,entl who tleee work fto rough gown employees,provided that
such Inprommems are not Inte ad or offered I Bele. tawever,the building or Improvement
Is add within one year of comple eowr,r Ilderwlll tine burden of provtrq that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of
❑I,ssAmer of the property,am exd connmctlrq with llcansed contractors to construct
the protect(Sec.]Saw,Business end Prot a Cod.:1`�ha CeniractWs License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property whobullde or lm thereon,andwhocontractsfor such prolec,-
with acontractors)licensed pursuant to the Co rectors lienee Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 5 P.C.for this reason _
Owner oats A
. WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fdbwrq dedaratbn:
.❑I neve and will maintain a Certificate e1 Consent to self-Insure for Worker-Compensation, Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which the //�
pe 01 lewancl /� / O ,1 jO
❑ hews ane will Une pelf Workers f the w sstlon Ineurenhis pe rant is Is by Section 3]00 of / U $eISfTLIC
the Labor Code,for the performance of the work for which the permit a issued.My Workers
-the
Insurance cenbr and Polity number are: Total �7, 7 n
Canter Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CC
(This section neod Tat be completed ft the permit is for one hundred dollars($1 N)or lose.) ^ fY
I certdy that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any mennor so m to become Subject to the workers'Compensation Laws of Cell- All roof^shall be inspected prior to any roofing mate 'al being
forma. - installed. If a roof is installed without first obtaining an.
Date' Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT:,eller�istom o rte LLabeorr Coa you i'you should t become Applicant understands and will comply with all non point
subject to the Workers'Com mit sh you moat brtlrwiM comply
with each provolone or this permit eheNbe deemed revoked. SOUfCe regulations.
I tartly that l have read this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and state laws relating to bulding construction," Al topf coveringstobeyclass or better.
hereby authorize representatives of thio dry to enter upon the ebove-mentbnetl property for Ion 71A'p`Lh/r//)� ��,, y / •specilm purposes. z, , n,� ' / p
(We agree to save,Indemnify and keep harmless the C ty of Cuperdw against Iiebllltles, n at /( . 6u I mak,, (p- 1
• ladpme nL-,toe,end expenses which may In any way accrue against ssltl Dlry In canaequenca
of the ITaniing of the parrtlt. -`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 ACCESST0 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 fust 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.
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: C L_1) A k'
ADDRESS:
RE-ROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-mof/winword