R-5430 APPLICATION FOR CITY OF CUPERTINO
rPE s RR- 5430
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (406)777-3226 PERMIT EXPIRES IF WORK IB NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL , COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME 'n` ^'%�•« root assembly is required:
p NO Initial I.C.B.O.N
ADDRESS z` •`-y�s�C -�••' �• EXISTING ROOF COVERING
PHONE vi ��V 7 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME
—
ADDRESS
TO BE REMOVED TO BE RETAINED
// TYPE OF ROOF COVERING J�¢/�/
ADDRESS /dri 6 '<Q 7 � SOS '4%dS �/- '�
CITV&ZIPS /��O 7tlo3y EXISTING
PHONE "�7— ���/9pp/"` BUILT-UP ROOF ❑ �0 /
LICENSE /ZT� /7 ASPHALT SHINGLES ❑ `� J
NUMBER l
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 01 the Business and Professions Code,and my license Is In full force and
effect.
C, 7Z74fy� WOOD SHINGLES ❑
License Class LIE.Number
Date -u- 97 Contractor OTHER(SPECIFY)( ❑
OWNER-BUILDER DECLARATION Oi y��
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason. PROPOSED Have
(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 ROOM' Q
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions �j
' of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code).or that he le exempt therefrom and the basis for the allegetl ASPHALT SHINGUES 0,99]
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($500).): / b,
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES c9 ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044.Business and Profes-
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ��V U •
not build or improve for purpose of sate.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a mntraotogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPEC$
❑1 am exempt under Sec. ,B S P.C.for this reason
AVX
OwnerDate APPLICATION DATE VALUATION MIT E
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
711 have and will maintain a Certificate of Consent to self-insure for Worker's Compensatlon, in�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
per It lsi etl.
ave antl will maintain Worker's Compensation Insurance,as required by Section 3700 of / $elSml
the Labor Code.for the performance of the work for which this permit Is Issued,My Workers
Compensation Insurance carrier and P�ol/mygnumber are: � Total
Carrier �� -72 POIIcy No.�1 / �o G 5l6-fl^ PERMIT AUTHORIZATION QAIE
CERTIFICATE EN ATION INSURANCE
FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars is100)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 subject to the Workers'Compensatlon Laws of Cell. All roofs shall be Inspected prior to an roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply wit 'non point
subject to the Workers'Compensation provisions of the Labor 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.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverin "Orbetter.
hereby authorize representatives of this city to enter upon the above�mentloned property for In. /J
spection purposes. Y—ZL X47
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilablllfles,
of the granting of this permidgments costs and t. SIGNATURE
which they in any way accrue against said CIN In consequence SIG ATURE OF APPLICANT DATE
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 TIT CITY OF CliPERTINO BUILDDiG DEP.4=NIENT
PRIOR TO ISSUANCE OF PERIIvQT A2ND INSPECTION PRASE.
1. Prior to pe mit issuance, you must a_ee to comply with U.B.C. standards and manufacr=rs rec's
on rercofrns.
2. Ne•.v roof coverings sbnll not be applied without first obtaining all inspection and Nwirea approval
from the building inspector. A final inspection and approval shall be obtained from the building
inscector 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,) P:einscection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verincadon
• b.) Spark arrestor installation
5. If plywood is installed,a plywood trail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all nex.
material down to the sheathing and a building inspector will inspect all sheathing at that time.
E UNDERSTAND TIS ABOVE POLICY ON REROOFING OA
AND WILL CPLY WITH
W7,;
POLICY
EO1'vIEOWNrRSNAbfE:
ADDRESS'..' -
REROOFING
DDRESS:REROOFING CO1vIPANYNAME: G tCydFi v�
APPLIC A,`+-I S SIGNATURE: —�--
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
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