R 6063 ' APPLICATION FOR CITY OF CUPERTINO
NU a RR- 6063
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDIN GA�DDRE$S. N D �. CA--J
] -J 1
I
/tZ ILY ✓Y\0 l�� `YO I.�
OwNERRESIDENTIAL COMMERCIAL OTHER
` HAZARDOUS FIRE AREA .
NAME L.\ V1 YES ❑ If yes-I understand that a Claw
roof assembly is required.
1 ( NO ❑ Initial I.C.B.O.It
ADDRESS- 1 n 6114. �.to U 0 EXISTING ROOF COVERING
PHONE LAD$)25
b - 3$ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S/A���
NAME
/�y` -e- ,P'1 L , U tr U TO BE REMOVED TO BE RETAINED
ADDRESS _ ,'� TYPE OF ROOF COVERING
CITY&ZIP 2TJ `__All '
EXISTING
PHONE LLD45 •E�9— k� ta� ! BUILT-UP ROOF ❑
LICENSE -
NUMBER /'?Q6S—� ASPHALT SHINGLES ❑
<--�D [
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. Q
WOOD SHING
License Class Llc.Number
Date Contractor
OTHER(SPECT AUG 21
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031,5,Business and Professions Code; Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROO ❑
By
applicant for such permit to file a signed statement that he le licensed pursuant to the provisions
• of the Contractor's License Law(Chapter S(commencing with Section 70001 of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the ale for the alleged ASPHALT SHINGLES ❑ r
exemption.Any violation of Section 7031.5 by any applicant for a permit sub] the applicant to C
a civil penalty of not more than five hundred dollars($500)J: ')
❑Iia°owner of the property,or my employees with wages as their a mpensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec,70 ,B s°and Proles- q ,i
alone Code: The Contractor's License Lew dose not apply to an owner of pr who builds or WOOD SHINGLES {OBJ
Improves thereon,and who does such work himself or through his own employe rovided that ❑
such Improvements are not Intended or offered for sale.If,however,the building I ovement
Is sold within one year of completion,the owner-bullderwlll have the burden of rovl adid OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed co� toc true Q
the project(Sec.7044,Business and Proleselons Code:The Contractor's U.m d PROVIDE I.C.B.O.REPORT N& �6J
apply to an owner of property who builds or Improves thereon,and who contredeR Ole S
with a contractor(s)licensed pursuant to the Contractors Ucense Law. p PROVIDE MFGR.INSTALLATIONSAP PE$. /5--2
❑I am exempt under See. ,B It P.C.for tls�r°s°op
Owner DateATIO Y APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to self-Insure for Workers Compeneellon, C!�- �—�(�/ �•/ O�U U Building IZ7•0 0
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Cl a
p It is issued. Seismic g0
1 have end will maintain Worker'°Compensation Insurance,as required by Section 3700 of
ih L or Code,for the performance of the work for which this permit Is Issued.My Worker's Total
Compensation I1 u�ra4!ccarr)f rand Policy number are: WO
c°rri°`— s 1" P°°ay"°, ��-a3ill- �"M PERMIT AUTHORIZATION DATE
CERT, KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. �--Ir—
(This section need not be completed 11 the permit is for one hundred dollars(5100)or less.) V O �A-�79rL..C.i Cc_ ��z���
I certify that In the performance of the work for which this permit Is issued I shall not employ
any person in any manner so as to become aubjec o the Workers'Comps sago Laws of call. All roofs shall be inspected prior to any roofing material being
Tornio. installed. If a roof is installed without first obtaining an
Date / z+ Applicant 4d inspection,I agree to remove all new materials for inspection.
subjectt t.theorkers'CompensaOT CE TO APPLICANT. If, tion pr lona of the(cateLabor Code,you
must toou rthwRhbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shel a deemed revoked, source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof e ' to be clas °(moi°Or better,
hereby)agree
t representatives of this city to enter upon they Of Cupertino
a property for In. `--� t
spectlon purposes.
p(Wen°Bros to save,expenses
and keep harmless the Clry of Cupertino egeinat liabilities, /I
• of the granting of this perrm,6 ea which may In any way accrue against geld City In consequence /granting of this "'bicb may In any way accrue geld inconsequence / SIWTU E OF APPLI �A T DATEE OF APPLI �A T DATE
PRE-INSPECTION: - PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DAT 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
SUBIECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPART ENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof 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,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
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 sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WrM THE
POLICY
HOMEOWNERS NAME: 0 N \ �I CA ^ 0/'� 'Vy-,
ADDRESS: :
REROOFING COIvIPANYNAME: t '
APPLICAINTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTivIENT
•
Reroof/wimvord
LXXX
• 0 0 0cy) 0 m
w w w w 3
4t
J JJ J
0 0 0 o
rn rn rn rn C
y
CA
1
Q] Co W W N
c c c C: i
CO CO W CO C
07 CO W CO N
N
1
m
m
rn
r
0
0 >o
m w x Z
Z C) v N
m m N N
M m
'9 0
-i o
ST GJ
C
(D
1 K O
� d
n �
m
m CD
o �+
w co co m
WCA
cNi rn N
co co m co00v
d
tD o
w °
co m
co 00 m
m
0
c
z
� � N
V
d
W `
z
e
co
co
co
m
•
c�
^� �o
�9�