99070051 41 .
[NNUMBER
ERII
APPLICATION FOR • CITY of CUPERTINO .
PERMIT
INSPECTION DIVISION PERMIT WO IS N -
REROOF PERMII (408)77]-3'x'8 _ PERMIT 130 DAYS IF PERMIT INOT SSUANCE
160 DAHIN 1 F DAYS S PERMIT IINSPE C I OR
1fJ0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS. r� _
IOp j 4QI Q• I f ON,c•, ''\On • , RESIDENTIAL COMMERCIAL OTHER
OWNER'S A HAZARDOUS FIRE AREA
. r•`I /�;,5 ../"n . [ �` YES ❑ 11 yes–I understand that a Class A
NAME l �' F" 1(i(.0/r J f assembly is required.:
NO. E Initial. LQB.O.A
ADDRESSy� '/,Y/5Q EXISTING ROOF COVERING
PHONE <b CT` 6, / d r 1. NUMBER OF EXISTING COVERINGS
CONTRACTOR'//S//�'I'//����
NAME �2as� Ram, _ TO BE REMOVEDf�o TO BE RETAINED
ADDRESS jq2 C'� ,(�Q�./ /,/ ;,.,/�J -1,r D� -��;/ TYPE OF ROOF COVERING
CITY a ZIP _JbtYu.t/-�'tiL�l/.(�1UJ� YitL..( "f• EX STING
..
PHONE—II �t" /
BUILT-UP ROOF
LICENSE 2�`� •� "'1 �.
NUMBER cid ll O� o�- _ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em loonseq under proveron,of Chapter 9(commencing with section WOOD SHAKES
]000)of DIAsIon 3 of the Business and Professions Code,and my license is In full lace entl -
effecT
can cle,55 ^'7 �23 WOOD SHINGLES
U
DS 39 lb.Number
Dateate *7
––2 convector OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
I hereby affirm that I am mempt hand Ne Contractor',License Lew for the folladng reason.
(Tec.7031.5,Business and Professions Code: Any city or county which requires a permit to
constmaL atter,Improve,demolish,or repair wry structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provd,ons .
of the Cantractor'o License Law(Chapter 9(commencing with Section 7000)of DNlelon 3 of the
Business and Professions Code)or met he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any vidatlan of Section 7031.5 by any applicant for a permit subjects the applicant to
a GNI penalty of riot more than Ilse hundred collas(5500).): _
❑L,as owner of the property,or my emplayeee with wagesm their sols compensetion,will do WOOD SHAKES y,J/
the work,end the structure Is not Intended or offered for sale(Sec.70x1,Business and Prof"- -
,ions Code: The Contractors LIcanso Lew does not appy to an owner of property who build,a WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,pronded Mel ❑
such Improrememse we rot Intend"or offered far sale.If,bowknot,the buiklkq or Improvement
is sold within one year of completed,the owner-buikter wilt hese Me burden of proving that he del OTHER(SPECIFY) ❑
not build or Improve ler purpose of sale.).
❑I,as owner of the property,am exclu,N Dry contracting with licensed contractors to construct
the protect(Sec.7044,Business and Pmfeesbnm Code:The Contractors License Law does rot PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property sono builds or Improves thereon,and who contracts ler such projects
with a contractor(,)licensed pursuant to the Contramor'e License Lew, PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sac. ,B&P.C.ler this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deciannich: /
❑I Neve and will rnalnteln a Certificate of Consent to self-raure for Worker's Compensation,
as prwded for by Section 3700 of the Labor Code,ler the performance of the work ler which this Building
Penton aIssued.
❑I have entl sola melntaln Wonkoro Camponeatbn Inaurantce,u required by Section 3700 0r' Seismic/
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's 7 7 0
Compensation Insurance carder and Pocky number we: –if Total �L�
CarrierJ?q �n PoikyNokj 1 5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[]
(This sabred need not be completed If the ponm0le 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 pecan in any manner so as to become subject to the Workers'Compensation LaA of call- All roofs shall be inspected prior to any roofing material being
fornix' ( installed. If a roof is installed without first obtaining an
Dere 7_ _ Applicant inspection,inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,shot making Mie Certificate of Exemption,you should became Applicant understands and will comply with all non point
sootect to the Wo*bho'Conpon,atfon provisions of the Labor Code,you meet forthwith mmpy,
with such provisions or this permit shelQbe deemed rmaked. source regulations.
I barfly Met I ha,,e read this application and state that the III Information Is cones-I agree[
to comply with all city and county ordthance,and state laws relating to building ccinw cticn,and All roof coverings to be class 6or better.
hereby authorize representatives of this city to enter upon the above nttoned property ler In-
apectfon purposes. •�J o'1
(We)agree to sere,indemnify and keep harmless the Clry of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said Clry In consequence SIGNATURE OF APPLICANT - DATE
of the granting of this 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.
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 ''/d' 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: _62
nI
ADDRESS: /07:395-
Q L
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re.ro Ywlnword