R-5617 APPLICATION FOR CITY OF CUPERTINO PERMIT
U e R R- 561
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
t RESIDENTIAL ✓/ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME �� VES ❑ If yes—I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.N
ADDRESR IO2r1i�U .�v - EXISTING RO F ERIN
PHONE NUMBER OF EXISTIN RINGS I
CONTRACTOR'S
NAME ' t 5 TO BE REMOVED TO BE RETAINED
ADDRESSI ' –� TYPE OF ROOF COVERING
.fCITV&ZIP W
^ L_ EXISTING
PHONE IC l � 72-44-55 BUILT-UP ROOF ❑
LICENSE 5713 I ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Sectlon WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES P410 ❑
License Class Lic.Number Imo^-'— � -/a'u
❑
OT Data /�B/a /J Contractor�• HER(SAWY 8//r//�
OWNER-BUILDER DECLARATION CITY z�(i7f
I hereby affirm that I am exempt from the Contractors License Lew for the lowing eason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requI ren to `rcyJ qq
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ��(J ❑ f
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 /
Business and Professions Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
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).): WOOD SHAKES
I]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 Profes-
sions Code:The Contractors 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 and OTHER(SPECIFY) ❑
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 Contractor's 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
�
I hereby affirm under penalty of perjury one of the following declaration: / /
-11 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUlldlna
Ml
ea provided for by Section 3700 of the Labor Code,for the performance of the work for which this �9, n L
permit is issued. 7/�t/h' S� 1� I Seismic LIN
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 y
the Labor Cotle,far the performance of the work for which this permit is Issued.My Workers
Com lion Insurance carrier Poli y number arej: � � 1�J�y� �'{—�t1 Total
Card IL 1 Vt t FopEy No. 1`mCi 'd PERMIT AUTHORIZATION T
CERTIFICATE OF EXEMPTION FI/OM 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 Cali. All roofs shall be In ed prior to any r offing material being
fornia._71installed. If a roof is installed without first obtaining an
Data ApplicantG �+w�'�G inspection,I agree to remove all new materials for inspection.
Como
aubjlecct t0 the Worrkers'Compensation proviOT CE TO APPLICANT: It,afrer sions of thelcate Lebo�Code.yolomuo fo thwithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shelCbe 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 slate laws relating to building construction,and All roof cc er'ngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
sD(We)agree
to�
(We)agree to save,Indemnify end keep harmless the City of Cupertino against liabilities,
of the gran costs and expenses which they In any way accrue against said Clry In consequence
of thegranengonnispermb. SIGNATURE OFAPPLICAN DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRE
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: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DE?PRT`IENT
PRIOR TO ISSUANCE OF PERZ�,IIT AND INSPECTION PI?-%SE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and mni
anufacrers sec'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,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke dete_•:or verification
• b.) Spark arrestor installation
S. If plywood is installed,a pivwoed nail inspec ion is required.
If any roof is applied without first o
6. btaining an inspection, you will be required to remove all new
` material down to the sheathing.and a building inspector will inspect all sheathin.g at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
EO vIEOWNeRS NAME: J
l u ✓ b$�o
REROOFu IG COMPANY NAME:
APPLICANTS SIGNATURE: Awn
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerocf/winword