R-5648 APPLICATION FOR CITY OF.CUPERTINO
PERMIT R- 5648
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
• BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
(�/� I YES E] If yes-I understand that a Class A
NAME 1 14e 1`I rl t) a- /^rco1 assembly is required.
�[7 Initial I.C.B.O.p
ADDRESSSUS �gSr'O '-�A��¢., �GA"�- EXISTING ROOF COVERING
PHONE S I Qct NUMBER OF EXISTING COVERINGS
"ONTRACTOR'SS
NAME ^ VY\ Cy r-, C Joy-,* C-G LT`\�Cw TO BE REMOVED TO BE RETAINED�_
4DDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE - cc—d BUILT-UP ROOF ❑
LICENSE SHINGLESfDC
LI NSED ONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cade,and my license IS In full force and
effect, WOOD SHINGLES q
License Class If�� `�1 Lic.Number Q S S I ` J
C� .s, OTHER(SPECIFY) y❑
Date P 2-xi 1 U Contractor ` - !!
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following 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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions e
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the 4Y
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT-$HINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to J
e civil,amity of not more than floe hundred dollars(h wag): WOOD SHAW_$24 ZIP-.
❑
❑Las owner structure
tureis property, tendedmy employeeswithfor saas le
rSola compensation,sand
Prlli s- KCSFI
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business entl Proles- C� Y
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD Sr1IN&LE& ❑
Improves thereon,and who does such work himself or through his own employees,provided that u
such Improvements are not Intended or offered for sale.If,however,the building or Improvement I'l�N�
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
O I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Lew. 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:
G -11 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building
permit is Issued. {_ 'o�V_�� 2�(j3,CSZ� Seismic
.gabor and will the performance
Worker's Compensation the work
for Insurance,as required by Section 3700 s rQ
the Labor Code,for the petormand of the work lar which this permit Is Issued.My Workers
compensation Insurance carrier end Policy number are: Total
carrier SJ.')QC ii(3 C AM 9 Policy No.9.h S`=0�
1�OOJ} PERMIT AUTHORIZATION DATE
CERTIFICATE OF EMPTION FROM WORKERS' y'S
COMPENSATION INSURANCE
(This section need not be completed it the permit Is for one hundred dollars es,) Lly
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 Lawe of Cali- All roofs shall be inspected prior to any roofing material being
fornia. n installed. If a roof is installed without first obtaining an
Date /0 aV -`1 Applicant _ ) NCC lira i La✓ inspection,I agree to remove all new materials for inspection.
subecct to th Workers'Compensation tion proviafter sionis of theicate of Labor Code.Exemption,
must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shell be doomed 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 be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, RLI=1
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT 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 THE CITY OF CUPEC INI O BUILDL�G DE?Aan IEV 1
PRIOR TO ISSUANCE OF PERMIT AN,) .- SD4SPECTION E.
1. Prier to permit iss tartcc, you mus a,r_ to comply with U.B.C. s and r s and rufacm ea sec's
on rercofing.
2. New roof rverings shall not be applied without first obtaining all ir=ecion and wrinen approval
from the building i=e^_tor. A final ince=tion and aoorovnl shall be obtained lom the building
inspector when the rercofing is comuletcd.
• 3. All types of roof shall be inspe^_ted prior to any rcof being installed
4. In order to receive a final,you must complete ceps 1,2, and 3.
1,) Preinscection or tear'off approval.
2.) In progress inspection approval.
3.) Final inspeclon approval.
a.) Operable smoke detector ve.•incatien
• b.) Spark are`tor insallation
5. . If piywped is installed,a plywood nail inspection is required.
6. If any roof is applied without first ootaining an inspection, you will be required to remove all new
material down to the sheathing and a building inscr-tor will in�c all sheathing at that time.
WE UNDERSTAND Tia ApOVr POLICY ON REROOFING P.ND WILL COMPLY =1Z Tr''
POLICY
-F)C3(?iT MD I _ 1 „ e-
_ NAb[E: \
PDDRESS:
ax 59n �Cl�l< �rtc �
REROOFING COMPANY NA.VE:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DE?ARTti[ENT
•
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