R-5678 APPLICATION FOR CITY OF CUPERTINO
rPE s RR- 5678
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WIthe DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS V `//^'
0SSTa-5CCl.I'i 7 �l RESIDENTIAL � COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
`pre p morpa- -- SES ❑ If yes-Iunderstand Class
NAME
roof sassembly is required.
NO Initial I.C.B.O.k
ADDRESS IHSS'—rasif_ ISIU QC•V EXISTING ROOF COVERING
PHONE
ase— CJO NUMBER OF EXISTING COVERINGS '
CONTRACR'S
l/1��/- TO BE REMOVED TO BE RETAINED
NAME
x ADDRESS ��I I TYPE OF ROOF COVERING
CITU&ZIP �-JlJ cJ C.(�.�[/'L EXISTING
PHONE 7 Y
q D BUILT-UP ROOF ❑ I
NUMBER &qg&a Lo ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby ahlrm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license is in full force and
effect. ❑ y`
WOOD SHINGLES
License as Lic.Number PA �D
Dale Contract OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED p�v �!y
� DL-n
I hereby affirm that I am exempt from the Contractor's License Law for the followln aeon. ICL V
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Cary (/
U�'
construct,atter,improve.demolish.or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF �ny
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions LUr6 /)N
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 0l rhe U
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).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.ll,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build 1a or improve for purpose of exclusively
. � �/
❑1,as owner of the property, an exclusively contracting with Contractor's
contractors to construct
the project owned property
who
Professions rImprov Cotle:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO.
apply to c fit owner al property whouant t or improves thereon,and who contracts for such prclecrs
with a am ex toys)n e r Se pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B 8 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:
❑I hav wtil maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
es provi diorb Section 3700 of rho Labor Coda,for the performance of the work for which this
Perini s Issuatl. 8 /91 g 1! `�— — Seismic
have and will maintain Worker's Compensation Insurance,as required by d.My
3700's //
the abet Code,for the performance of the work for which Tills permit Is issued.My Worker's Total
Comps�lie{�In-aur cater' dPolicyn bar are: / �J /�
Carrie C>ti /_i� / —� / PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E)
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
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 aub'act to the Workers' Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. w] installed. If a roof is installed without first obtaining an
DatA43 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: IL after making this Carfific of Exemption,y u should become Applicant understands and will comply with all non point
subject I.the Workers'Compensation provisions of the L or Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be ClaS rbetter.
hereby authorise representatives of this city to enter upon the above-mentioned property for In.
/f (�/�prV,✓ v���
hereby 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
of the granting of this permit. SIGNATL09E OF APPLICANT DTE
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: REROOFING POLICY FOR Tri CITY OF CLPERTINO BUILDDIG DE?PRTi EN
PRIOR TO ISSUANCE OF PERM T AND I`NSPE'`TION P LkSB.
1. Poor to pc.=it isruanc2, veu must ,
ee to comply with U.B.C. standards and martufacnLre:s spec's
on rercof[ng.
2. New roof ccverings shall not be :colied vvithput first obtaining all inspec:ion and written approval
from the building in�r_:or. A finalin�e :ion and approval shall be Obtained from the building
from
when the rereof[ng is campleted.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to recoive a final,you must complete steps 1,2, and 3.
1,) P:ei=.—tion or tear off approrl.
2_) In pro;ess ins?e—cdon approval.
3.) Final i=erlon approval.
a.) Operable moire dere=:or ve in(=tien
b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inrec:ion is required
6. If any roof is applied without first obtaining an inspection, you will be required to rernove all new
material down to the sheathing and a building inspector vviil in�e�_,all sheathing at that time.
�yE UNDERSTAND TI-.r ABOVE POLICY ON REROOFi?`7G Plv"D W1I..L CObCPLY WITF_ irj.
POLICY
09
FiOiViEOWWc?.S NAME:: Ms US=12�71/4�ct—
ADDRESS: `
REROOFNG CObiPANYNAME:
i
APPLICA,`+TS SIGNATURE:
Cr7f OF CUPERTINO
BUILDING DEPAR'P ANT
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