R-5534IV
•
OFFICE COPY
PERMIT R- 5534
APPLICATION FOR CITY OF CUPERTINO NUMB
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
RESIDENTIAL—X—COMMERCIAL OTHER
OWNER'S_
HAZARDOUS FIRE AREA -
YES ❑ Ilyes-Iunderstandthata ClassA
NAME `�`'�e'v
roof assembly Is required.
NO '-L,4 Initial I.C.B.O. fl
NO
l�1
ADDRESS on
ROOF COVERING
S�,ke s
^`7
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
NAME ✓I
/� �/
lI ki volIQ eb&G 1V>9
TO BE REMOVED ! ' TO BE RETAINED
ADDRESS `x/34
sly
TYPE OF ROOF COVERING
clTv a zl ;% =l R
EXISTING
PHONE
❑
BUILT-UP ROOFLICENSE
/ �.
NUMBER
ASPHALT SHINGLES ❑
/N/OOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
License Class `C LIC. Numbeer (� �
WOOD SHINGLES ❑
1
Date g `Z'j,g'�- Contractor Jl \�I Cal iuxa �AO�h[
(SPECIFY) PA 161 .
ROPO
q
OWNER -BUILDER DECLARATION o
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the
applicant for such to file a signed statement that he Is licensed to the
4
,,/� F1 7
BUILT-UP ROd%�'
V'
permit pursuant provisions
of the Contractor's License Law (Chapter a (commencing with Section 7000) of Division 3 of the
F L'Ur
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ENT/
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars (5500).):
WOOD SHAKES /
C] h 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 Profits.
sions Code: The Contractor's 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. ll, however, the building or improvement
Is sold within one year of completion, the owner-bullder 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 contractor(s) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am 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:
❑ 1 have and will maintain a Certificate of Consent to self -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 lssuetl.
Seismic
F7I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Total
Compensation Insurance carrier and Policy number are:
d �- 9�
PERMIT AUTHORIZATIO
DATE
Carrier `-A7lC _'72n Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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 manner so as to become subject to the Workars' Compensation taws of Cali-
All roofs shall be inspected prior to any roofing material being
forma.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply With all non Om(
PP P Y P
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
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. I agree
to comply with all city and county ordinances and state laws relating to building construction and
All f coverings to be class O better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
apache) purposes.
(We) agree to save, and keep harmless the City Cupertino against liabilities,
L
peindemnifyesw ai
costs and expenses which may In any way accrue against said City in consequence
AT OF PLICANT DATE
ofjudgments,the gran
of the granting of This permit.
PRE -INSPECTION:
PLYWOOD:
IN OGRESS:
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
n
U
•
n
lJ
SUSIECT: REROOFING POLICY FOR THE cl ct'TOF CUPEc I NO BUILDENG DEPART IENI
PRIOR TO ISSUANCE OF PERNII T AND INSt ION P." SEE.
1. Paas to pe mit isstat ce, you mu<_t agree to comoiv with U.E.C. s't.acards and n ufac; ea sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and wnttea approval
from the building ince :or• A final inspection and approval shall be obtained from tie building
inspector when the re:eafing is completed
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to re^_c:ve a final, you =,q complete reps 1, 2, and 3.
1,) P:einsce^_tioo or tar off approval.
2.) In progress inspection approval.
3.) Final insoe=Son approval.
a.) Operable smoke del.—tor verification
b.) Spark arestor installation
5.. If plywood is installed, a plywcpd pail inspection is required
d without first obtan
6. If any roof is applieining an iception, you will be required to remove all new
rnntedal down to the sh=ddng and a building inspector will inspe—_, all sheathing at that time.
NvE UNDERSTAND -rHE ABOVE POLICY ON REROOFING PND WILL COMPLY WITti THE
POLICY
EONIEOWNcRS NANNT:
ADDRESS.
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerooftwinward
,I- CO60wj