R-5811 rfl'
APPLICATION FOR CITY OF CUPERTINO
nPE s RR- 5811
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR r
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I ob(0'7- r o 6 6q RESIDENTIAL P"� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
M/M k 11-0 ya wl a YES ❑ It yes-1 understand that a Class A
NAME 1 roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS � 6�� Mg (�I�WOOd Lh EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Q,.,
NAME Ileylot I S sA iii ' `� n� 9 TO BE REMOVED TO BE RETAINED
'j
ADDRESS .2d�-, L I H C O J i j y C TYPE OF ROOF OVERING
CITU 8 ZIP
EXISTING /
PHONE 4 —O G BUILT-UP ROOF J\ 6
NICENSE igUMBER I r' 4'7 5 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Cade,and my license is in full to"and
effect
�
License Class C 3� Lie.Number S J•q �3 WOOD SHINGLES
12-a4•-g7 �hGyO10C'a.n�au OTHER(SPECIFY) ❑
Date Contractor s
OWNER-theCoBUILDER DECLAR ON PROPOSED PAID
hereby affirm Bu that I em exempt from the Contractor's License Lew for the requires
a reason.
(Sec.]ct,alt ,Improve and Profedemolish.
or rep Code: Any urs or county which re,also a permit to
construct,alter,Improve,to file signed
or repair any structure,prier to its Issuance,also requires the BUILT-UP ROOF ❑ RE
applicant for such permit to file a Chaps statement that he islicensedSection
pursuant to the provisions D�4 RECD
of the ss and Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 0l the L7 RL ID
Business and violation of Coda)or that he is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to n_
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES V 11 Y�F uurEHTIN0
I,as owner of the property,or my employees with wages as their sole compensation,will do LJ
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: I7
-11 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this OOO BUlldlnr� / , n
permit is sed. (i'' I2 Seismic `,
eve and will maintain Workers Compensation Insurance,as required by Section 3700 of
,the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's '?/� ' Total • �",ry7 D
Compensation insurance carrier and Policy number are
Carder S—hVL+e iAd Policy No. "2 �S 7 PERMIT ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
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 subject to the Workers'Compensation Laws of Cell- All roots Shall Vinspected prior to any roofing material being
forma. installed. If roof is installed without first obtaining an
Date Applicant inspection, agree t0 remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shalr;be 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. e�-O 12-24-
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, fly ^^CVJ
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this perSIGNATURE OF APPLICANT DATE
mit.
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 NAME: M( M 1<"+.P-
ADDRESS: 24' 0 ( mea p(e vooa( Lvt
RE-ROOFING COMPNAY NAME: PEha(SSaA «
APPLICANT'S SIGNATURE:
,r,=rPi, �
CITY OF CUP,ERTINO���(1
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BUILDING DEPARTMENT n DEC , 2 19 � 5
DEC 2 4 1997 a nG m',JN DEF
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BLDG. INSPtLT&�' , w+ � 2 1997
a - rorn ,w2LaU INSPECTION DEPAR'uvitrv(CITYOFCUr 1ININ0
CITY OF CUPERTINO� BLDG. 4PECTION DEPAR uv try l
S CITY OF CUPERTINO