R-5328I
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OFFICE COPY
PERMIT
5328
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK 15 NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
CO
RESIDENTIAL MERCIAL OTHER
OWNER'S - {/�'
�O�/
HAZARDOUS FIRE AREA
VES ❑ I understand Nat. Class A
'-GG /�
yes
NAME / �'/
��
root assembly is required:
NO - Initial LC.B.O. q
�/
EXISTING ROOF COVERING
ADDRESS c�/DO
-
,—�/�7
PSiONE i
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
NOME
ADDRESSja C--L/%%7�
TYPE OF ROOF COV RING
CITV BZIP LLJ` ��
EXISTING
PHONE �L S / — (O �S ,%
❑ f`!/�
- BUILT-UP ROOFLICENSE
NUMBER
ASPHALT SHINGLES ❑ j)l'
f
WOOD SHAKES rVY
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am Ilcenaed under fessions of Chapter 8 (commencing calif force and
]000) of OiviBlon 3 of the Business and Professions Cotla. and my license Is in lull lona antl
effect.
WOOD SHINGLES ❑
License Cless Lic. Number
OTHER (SPECIFY) ❑
Date 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 Cr county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF E]applicant
for such permit to fila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter g (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLESPEI
exemption. Any violation of Section 7031.5 by any applicant for f permit subjects the applicant to
�+ Q
a civil penalty of not more than five hundred dollars ($500).):
WOOD SHAKES � y 6d 1
❑
❑ I, as and
er the structure for eels (Sec. 7044, Business entl s-
the work, entl the structure is not Intended ore Profes-
I not I my tended or aes ltered wages as (Sec.theirsole compensation,sand
sions not builds or
WOOD SHINGLES ❑
esthTheContractorsLicenseLewdoesnotapplytoenownerofpropertywhobuildsor
Improves thereon, and who does such work or through his own employees, Improved that
_
or red for however, the
such Improvements are not offered for sale. or Improvement
Is completion,ow ill
leb n, the ownerbulltlerwill have the burtlan of proving that he did
burdenpr
OTHER (SPECIFY) ❑
not build s
ld or I provefor purpose
not bulltl or Improve for pur0oea of sale.).
[-] 1, I, as owner of the property, em 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 contraclogs) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt undal�. .B 8 P. C. for this reason
i c
n,.,de.�C�iw ai Date
v ) WOR �R'SCOM ENSATION DECLARATION
APPLI T ,h E VALUATION
PERMIT FEE
APR- �
Buildin
�
I hereby affirm under penalty of perjury one of the following declaration:
1 haC and will maintain a Certificate of Consent to self -insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
�^
4
J'permit is Issued. and Insurance, as required by Section 3700 of
have entl will maintain Worker's Compensation
Labor Code, for for Is leauetl. Worker's
��/y�, �/y
AI \(/DVI
J� lV/
CITY OF cur tHTI
Seismic
1
I.
the the performance of the work
the workfor which this permit My
111
Tota
Compensation Insurance carrier and Policy number are:
Carrier Policy No
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(:]
(This section need not be completed It the permit Is for one hundred dollars ($100) 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 Workers' Compensation Laws of Call-
All roofs shall be inspected prior to any roofing material being
tornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: It. after makints Cerifcate ou shoud become
f Exemyou
Applicant understands and will comply with all non point
subject tithe Workeres'Compensellon provisions of thlelLaborCCode, mush forthwllth 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 roof Coverings to be class "C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
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spection 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
SI NAT RE OF�APPLICANT DATE
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD:
IN -PRO SS:
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
Ll
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERVIIT AND D45PECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufac: sea sec's
on reroofing.
2. New roof coverings shall not be apolied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1, 2, and 3.
1,) Pre;nspectioa or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
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b.) Spark arrestor installation
5. If plywocd is installed, a plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspr all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TrM
POLICY
HOMEOWNERS NAME:
a g,ADDRESS:
REROOFING COIv1PANYNAME;
APPLICkN7S SIGNATURE:
CIT`! OF CUPERTNO
BUILDING DEPARTMENT
Reroof/winwdrd