R-5501 APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 5501
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNi1 1 „ HAZARDOUS FIRE AREA
VES ❑ If yes I understand that a Class A
roof assembly is requiretl.
� NO ❑ Initial C.B.O.IIt
ADDRESS-.0 2 OEXISTING ROOF COVERING
NUMBER OF EXISTING Z NG COVERINGS I
PHONE
CONTRACTO Q(� ///�
TO BE REMOVED TO BE RETAINED
ADDRESS�� �� � � TYPE OF ROOF COVERING
ClTvazlP I r� EXISTING
PHONE \n�{ —� BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
—LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES y�l
7000)of Division 3 of the Business and Professlons Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License ClaS -d Lt..Number R�
OTHER(SPECIFY) ❑
Data -BUILDER
NER-BUILDER AU a PROPOSED
hereby affirm that am axe pt 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 Contractors License Law(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES e1
exemption.Any violation of Section 7031.5 try any applicant for a permit subjects the applicant to P 1 1)
a civil penalty of not more than live hundred dollars($500).1: WOOD SHAKES El I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles. ee
sionsCotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES rd� ""`�"'�(�
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-bulkier will have the burden of proving that he did OTHER (SPECIFY) OffYi f'[EyrEN(INO
not build or improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.'INSTALLATION SPECS.
❑1 am exempt under Sac. .B a P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. (/�� Seismic
❑I have antl will maintain Worker's Cam nation insurance,as required by Section 3700 of
the Labor Code,for the performance of t work for whlCh this permit Is issued.My Worker's 1 Total
Comp sell n Insu an e c rtler and Polio comber ar�xf /((�� 1
^ Ili
carrier Pollcvll No. PERMIT AUItPRIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' t
COMPENSATION INSURANCE N.C.D V
(This section need not be completed If the permit is for one hundred dollars($100)or lees.)
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'Co .natio Laws of�all- All roofs shall be' pected prior o any roofing material being
Data '—1 / ) installed. It a of is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTIc A L A after making this Certificate of Exe eon,you a oma become Applicant understands and will comply with all non Dint
subject to the Workers Compensation provisions of the Labor Code,you must forthwith comply pp p Y p
with such provisions or this permit shaffbe deemed revoked. 'Source regulations.
I certify that I have read this application and state that the Shove Information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to belting construction,and All roof covennos too SS Or better. I `�
hereby authorize representatives of this City to enter upon the above-mentioned property for I /
spectre)n purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT ATE
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
SUBJECT: REROOFLVG POLICY FOR 'ME CITY OF CUPERTINO BUI DIDiG DE?A.R MEN i
PRIOR TO ISSUANCE OF PER:' AND N„pEC t tON P�LkS'c.
1. Poor to pe mit iss tattoo, you mus agree to comply with U.B.C. standards and manufac: rota sec's
an reroofing.
2. New roof coverings shall not be applied without first obtaining all itt_'ec:ion and mine^ approval
t from the building inspector• A final tn_tiecuon and approval shall be obtained from tiro building
inspector when the re.cofing is completed.
3. All types of roof shall be inspe^_:ed prior to any roof being installed.
4. In order to re^_cive a final,you mun completc steps 1,2, and 3.
1,) P.cinscection or ter off approval.
2.) In progress in_nt e`don appro,6ml.
3.) Final inmec—don approval_
a.) Operable smoke de,.--.or ve:ncat=an
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail ince-_'tion is require3
6. If any roof is applied without fits obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building i=e^or will inspe_all sheathing at that time.
WE UNDERSTAND Tr ABOVE POLICY ON REROOFING PND WIL COivIPLY WITH HE
POLICY
EOivlEOWNERS NAME:
ADDRESS:*
REROOP u iG COMPANY NAVE:
APPLICANT'S SIGNATURE: ��_
CI1 f OF CUPERTNO
BUtLDNG DEPART;IENT
•
Rerooflwimvord