R-5544i
OFFICE COPY
PERMIT '
5544
APPLICATION FOR CITY of CUPERTINO NUMBERR_.
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1 \,0
RESIDENTIA COMMERCIAL OTHER-
OWNER'S
HAZARDOUS FIRE AREA
�p ,,' l%
ICA �Q.
ss A
YES hoof
NAME 1.) f�� {� t i
assembly s required.
NO Initial I.C.B4O. k
y
I, ' �' 1'C�
EXISTING ROOF COVERING
ADDRESS %0 t11 jnf ✓ 1
�-a �0 3
NUMBER OF EXISTING COVERINGS
PHONE -
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESSi
D
TYPE OF ROOF COVERING
CITY R ZIP
EXISTING
1p, G
PHONE Li� I l� `-�
BUILT-UP ROOF
LICENSE l -J' cLO'Tl
NUMBER V
ASPHALT SHINGLES ❑�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES Eleffect.
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
2
License Cis s �� Lic. Numb
WOOD SHINGLES ❑
`
If2jIOTHER
(SPECIFY) ❑
Dale Co rector
1Pe (J
P
OWNER- LARATIO
%
PROPOSED
I hereby affirm that I am exempt from the Contr tor's License taw for the following reason.
(Sec. 7a31.5, Business and Professions Code: An I or cc which requires a permit to
construct, alter, Improve, demolish, or repair anyatructur o its issuance. also requires the
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4y
applicant for Such permit to fila a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF
Cqp
of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
n 4 ii99
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGL91 Y Uf ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
five hundred dollars
(,UP
rlNp
a civil penalty of not more than ($500).):
WOOD SHAKES O
❑I, as owner of the property, or my employees with wages as their Bale compensation, will do
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 C]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
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Is sold within One year of completion, the owner-bulltler will have the burden of proving that he did
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
❑ 1, 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 corrosions) licensed pursuant to the Contractors License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,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:
❑ 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.
aveandwillmaintainWorker'sCompensation Insurance, as required by Section 3700 of
4 \kj�—[,
.�
Seismic
the Labor Coca, for the performance of the work for which this permit Is issued. My Workers
Compensation Insurance carrlerend Poli number are: 1 r
-,cyNo. b
N0
F�
Total
PERMIT AUTHORIZATION
DATE
Carrier '^r��A,C - � Policy
CERTIFICATE EXEMPTION FROM WORKER
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 w ich this permit Is Issued. I shell not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to becon ec t0 ,e Bnsahon Lat c If
rornie. -
installed. If a roof is installed without first obtaining an
Date g % , I_nt
inspection, I agree to remove all new materials for inspection.
NOT1C TO APPLICANT: If, Iter making t er o Exempt , you should become
subject to the Workers' Compens ,e Lab Code, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y
with such provisions or this permit shall be d emed revoked.
Source re ulations.
I certify that l have read this application a state that trove information is correct. l agree
18SS "Ci" rbetter.
to comply with all city end county ordinanCo.. ewe relating to building constructionantl
hereby authorize representatives of this city to enter upon the above-mentionetl property for In-
OOf COVerI Obs
/
spectlon purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against Ilebllltles,
O 1
judgments, casts and expenses which may in any way accrue against said Chy in consequence
E'
FAP T DATE
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: REROOFING POLICY FOR Tri Crl-Y OF CUPEeTNO BUII.DCiC DEP.Ri`LFV 1
PRIOR TO iSSU,\-NCE OF PEP VQ T AND `NI PECt ION �_'c.
.-:rtit issuance, you mus:
1. Prior to peagree to comply with U.H.C. s ncards and manufacn ea sec's
an reroofing.
2. New roof coverings shall not be applied without first obtaining all in_cection and ttTiuca approval
from the building inspe_tor. A final tnspecuon and approval shall be obtained from the building
i=cc:or when the re:aofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
3. In order to receive a fin:`t al you mcomplete steps 1, 2, and 3.
1,) P:einspec:ion or tear off anprcval.
2.) In progress in_soe=:ion approval.
3.) Final in=cc-ion approval.
a.) operable snake detector vetiiicat an
b.) Spark arrestor installation
• 5.. If plywood is installed, a plywood nail inspection is require
6. If any roof is anplied without first obtaining an inspection, you will be required to remove all new
material dawn to the sheathing and a building inspector will inspect all sheathing at that time.
NE UNDERSTAND Tr~- ABOVE POLICY ON REROOFING PND WILL COvIPLY WIT Tr'r
POLICY
FOiv[EONNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICA,N 7S SIGNATURE:
CITY OF CUPERTNO
BUiLDNG DEPARTZMENT
Is Rerooflwinwbrd