R-5641 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5641:1 641
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
eol�
3! RESIDENTIAL V COMMERCIAL OTHER
NER'SHAZARDOUS FIRE AREA
L/c1 yrs r/. A , YES ❑ tf -I understand that a Class A
NAME YL ���CC d L �f (—y/ /C oof assembly is required.
�✓1 NO Initial I.C.B.O.N
ADDRESS�� 31(���I e�- EXISTING ROOF COVERIIN.G�
PHONE — V NUMBER OF EXISTING COVERINGS V) !;1
CONTRACTOR'S
TO BE REMOVED_30-TO BE RETAINED
NAME / L
CITVRTYPE OF ROOF COVERING
&Z P _J.�C�Sa�!/ S'"f S,
EXISTING
PHONE — 2 BUILT-UP ROOF ❑
s NIUMBER d D ASPHALT SHINGLES ❑
LICENSYD CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full ferc7tl
effect.
� 01 OOD SHINGLES ❑
License Class Lie,Number
Data Caratory/�7�.ay O U OTHER(SPECIFY) ❑
OWNER-BUILDER CLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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 ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the U� ��// II�,
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLESr- = V
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKRR 3 0 1997 ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
stone Code:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES
Improves thereon,and he does such work himself or through his own employees,provided that ❑ k /y
such Improvements aro not intended orw offered for sale. ill however,the building or improvement uLLfU, I P TION DEPAR
I s eoltl within one year of completion,the owner-builder will have the burden of proving that he did ER$ ��
not build or improve for purpose of sale.). OTH I CUPERTINO
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct IL1,pAl(Q Y—
the project(See.7044,Business and Professions Code:The Contractor's License Law does net PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,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: /!`- O
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, J�.� D_ Qj // O A/5 Building f c u
t as provided for by Section 3700 of rho Labor Code,for the performance of the we rkfor which this 7 / l� l.�J '' ,,
permit Is issued. Seismic 0
have and will maintain Worker's Compensation Insurance,as required by Section 3700
_rhe Labor Code,for the performance of the ware for which this permit is issued,My Worker's
/,.s
f 4 D
Compensation Insurance carrier end Policy number are: Total
Carne- Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE Nall o
(This section need not be completed it the permit is for one hundred dollars($100)or less.) / S
certify that in the performance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Law$of Car- All roofs shall be inspected prior to any roofing material being
Ionia. 4 l installed. If a roof is installed without first obtaining an
Date Applicant &7eiilinspection,I agree to remove all new materials for inspection.
NOT( E TO AVIi If,after making thit Certificate of Exemption,you$ sum became Applicant understands and will comply with all non point
subject to the Workers'Compensation previsions or the Labor Code,you must f thwith comply pp P Y p
with such provisions or this permit shah be deemed revoked. Source regulations.
I certify that I have read this application and stare 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 far in- C \
spection purposes. 3e
(Wal agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. ATURE OF APPLICANT ATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
(NSP. 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
SUBJECT: REROOFING POLICY FOR ThT CITY OF CUPERTPIO BUILDD;G DEPARTNCENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PF—AS''
1. Prior to per,nit issuance, you must agree to comply with U.B.C. standards and manufac:urers 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,) P:e;=e-tion or tear off approval.
2.) In progress in-Yection approval.
3.) Final inspection approval.
a.) Operable smoke de:e—or veriacadon
• b.) Spark arrestor instillation
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 CONIPLY WITH THE
POLICY
HONIEOWNERS NAME:
ADDRESS:`. n
REROOFING CONfp, ..NY NAME: �
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/winw6rd