R-5277 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5277
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.
BUILDINGf)ISO RESIDENTIAVr�//�� COMMERCIAL OTHER
OWNS Iy^y^1 HAZARDOUS FIRE AREA
NAME 1 ' YES ❑ It yes-I understand that a Class A
roof assembly is required.
_
NO Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE � ^ ,� /►� , /��( 3 NUMBER OF EXISTING COVERINGS
-�.J(�j��L{r� f
TO BE REMOVED - TO BE RETAINED
NAM
TYPE OF ROOF COVERING
CITY&ZIP —1 J� ��`'(1 l .►'\
— EXISTING X
P�E Lid, `rU 3�-3 BUILT-UP ROOF 41
LICENSE
NUMBER (�Z — \1 kJ
ASPHALT SHIN%ES .10
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES �%L 1T2�
7000)of Division 3 of the Business and Professions Code,and my license Is In full force anL(/
d `1,-
effect. WOOD SHINGLES Q]
License ss U.,Numb
Date contract OTHER (SPECIFY) ElOWNER-BUILDER DECLARATION PROPOSED
I hereby Irm that I am exempt from the Contractor's License Law for the foltowing 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 ❑ �'7
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions C
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the h,
Business and Professions Code)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).8 WOOD SHAKES
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-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES El
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 completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
I,as owner of the property,am 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 contrectons)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I
I hereby affirm under penalty of perjury ono of the following declaration: r '�
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building
as or f
provided
ed by Section 3700 of the Leber Code,for the performance of the work for which this
permit is issued. (_-\1 �.I{// IX 'LJ\
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 Seismic
„the Labor Cotle,for a performance of the k for which this permit is issued.My Worker's
Compo io nsur Ce erne ndPolicynu erere: Total
Carrie. _ �A POlicy�Io! 1 , �� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC
N.C. .
(This section need not be Completed if the permit is for one hundred dollars(5100)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 m nner s�aiit o become subject to the Werke compo setlon Laws of Cali- All roofs shall be inspected prior to any roofing material being
forni installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPL CANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Lobar Code,you must forthwith comply PP P Y P
with such provisions or this permit shalQbe 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 state laws relating to building construction,and All roof coverings to b G ss"CI' r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. v _ v l s-/23_4 y
spection purposes. J
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
' of tthe gr granting of this perrmit es which may in any way accrue against said City In consequence SIGNATURE OF APPLICANT r)
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTIi10 BUILDLVG DE?P.RTNIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PF--�SE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufactures tee's
on reroofing.
2. Nc,,v roof coverings shall not be applied without first obtaining all inspection and written approval
tion and aporoval shall be obtained from the building
from the building inspector. A final inspe
inspector when the reroofing is completed.
r -
3. All types of roof shall be inspe^_ted prior to any roof being installed.
•
4. In order to receive a final,you mta_a complete steps 1,2, and 3.
1,) P:einspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Oce nble smoke dete^_tor verification
. b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inscectioa is required.
6. If any roof is applied without firs obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspec all sheathing at that time.
E UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CObfPLY WITH Tri
W
POLICY
HOMEOWNERS NAME:
ADDRESS:'
r
REROOFING COMPANY NAb1E:
APPLICA`T S SIGNATURE:
CITY OF CUPERTINO
BUILD NG DEPARTNIENT
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