R-6009 INSPECTION DIVISION PERMIT R_ .600
9
APPLICATION FOR CITY OF CUPERTINO NUMBER
PERMIT EXPIRATION
REROOF PERMIT (4W)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WRHIN 1W DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM I-ST CALLED INSPECTION.
BUILDING ADDRESS
.r1
C, RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
/ey YES ❑ If yes—I underWand that a Class A
NAME � ((( roof assembly is required.
NO ❑ Initial I.C.B.O.1
ADDRESS �L�% ��+ �iLrr✓'�.....G� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS ��0
CONTRACTOR' - ,�/
��S / TO BE REMOVED 1� TO BE RETAINED
NAME Q /��
ADDRESS /�/� PE R F V
'CITY azip�. o)��OS /�17ra�s�a.�e� C/9 EXISTING -
PHONE /Qr�— 33G^ 3G 76 BUILT-UP ROO ❑
LICENSE y ��� ASPHALT SHINGL
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under proviskxe of Chapter a(commencing with Section WOOD SHAK< ❑
]000)of DMsbn 3 of the Business and ProfeauOr'S Code,and my license b In full force and
effect. WOOD SHINGLE$ r ❑
Ucense Cl... C� —39 Uc.Number
Data Conv
7 27-%� OTHER(SPECIFY) ❑
� '- ect
OWNER-BUILDER DECLARATION. PROPOSED
I hereby affirm Mat I am exempt from the Conlnmors License Lew for the following reason:
(Sec.7031.5,Business and Profeasbru Coda: Any cry,or county which lectures a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,aft requires the BUILT-UP ROOF I
applicant for such permit to file a signed statement Met he is Ilce sad pursuant be the provolons
. of the Contmctore Ucanse law(Chapter B(carrnendng with Section 700()of Dwislon 3 of the V
Business arid Professions Caere)or that he Is exempt therefrom and me basis for the alleged ASPHALT SHINGLES.
wamptbn.Any Aclatbn of Section 7031.5 by any eppllcant for a Permit Subjects the applicant to
a civil penalty of not more than five hundred dollen($500).): A
01.as owner of the property,or my employees with wages as than sole compensation,will do WOOD SHAKES I ❑
the Work,a.M me strucenre Is not Intended or offered for Bele(Sec.7044,Business and Profes-
sions Code:The Contractors License Lew does rot apply to an owner a property who bunds for WOOD$�l L'�7 FWD El
thereon,and who does Such work himself or through his own empkryaes,provided Met v V WN
Such Improvements are not Intended or offered for sale.If,however,the buldln g or Improvement
Is sad wrNn ore year of compbron,the owner-builder will he"the burden of proving that he did OTHER,f$PECIFY) Elnot build or Improve for purpose of Sale.). L I Y Ur V UI-CTt 1 jNU
❑1,as owner of the property,em exclusively,contnctin with licensed!contractors to construct ,
the project(Sec.]044,Business and Professions Cade:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulls or improves thereon,and who contracts for such projects,
with a conmictogs)licensed pursuant to the Contractors Ucenae law. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B&P.C.for rola reason
Owner Date
WORKER'S COMPENSATION APPLICATION DATE VALUATION PERMIT FEE
-
I hereby affirm under penary of perjury one of the following daclantlon: L�
-11 have and will maintain a Certificate of Coneent to aeraneuro for Workers Compensation, UI ding
as provided for by Section 3]00 of the Labor Code,for Me perlormarne of the work for which MIS
permit Is lasted. ��) 3 �� Seismic
❑ have and will themaintain Workere f On,woo,for
Insurance,as required it15by Section 3]00's - (/
the Labor Cade,for the pander anroe of the work b which this pertnr W Issued.My Wohere 1 Total
Compartaetlon Irtsureue carrier and Polley number are: MEW
Carrier Policy No. PERMIT AUTHORIZATION
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.CQ
(Thie saoflon need not be completed It the permit Ie for one hundred dollare($100)or few.) 7
1 canlfy mat In Me pedonmanpe ol the work for which Mile permit Is Luted,I shell not am
L
any person fn any manner mo of to become subject to tie Workers'ComPeneatbn laws a ' All roofs shall be inspected prior to any roofing material being
-
ferrle. rr-- ,�Lc----- installed. If a roof is installed without first obtaining an
Date 7 Applieainspection,I agree to remove all new materials for inspection.
NOTICE to t e o*em'APPUCNr: b,aver making iris f Me Lab of Ex wren,must forthwith ca°py Applicant understands and will comply with all non.point
subject to T Workers'Compensfter eking MIS of Ma Leber Cada,
with such provisions or this permit shale be deemed revoked. - Source regulations.
I certify Mat I have read this appllcaton and state that the all Information Is correct.I agree
to comply with all city and county ordinances and ante laws relating to bullding cbru;ualon,and All roof coverings to be clSS 611 or better.
hereby authorize representatives of this city to enter upon the abov whltoned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,poste ane expenses which me,In arty way accrue against Said Clty In consequence
of ire granting of this permit. SIGNATURE OFAIPPLICONT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR 'OFF INSPECTION' BATTENS: FINAL
ell
INSP. SPDAT2/I i INSP. DATE - INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTvENT
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.
I,) 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 WITH THE
POLICY
HOMEOWNERS NAME:
ADDRESS: : X& z o?, .44l rll� cLL
REROOFING COMPANY NAME:
s• in 1Nc.
ti— u
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
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