R-5524Cl
OFFICE COPY
PERMIT R- 5524
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
T
10301 A-I rev F
{J�r
RESIDENTIAL COMMERCIAL OTHER
OWNER'S /'
HAZARDOUS FIRE AREA
'A 1^ ,� ,, n al
or 0 401
YES E] 11 yes — I understand that a Class A
NAME ' V t- 1v 1
roof assembly is required.
NO Initial I.C.B.O. g
/ 1,4/, 1 �' w..�w
7b 94040
EXISTING ROOF COVERING
ADDRESSd'^ 0' ��k —T--� • t t+r• Vf tl
^ 37'7
NUMBER OF EXISTING COVERINGS
PHONE
CONTRAC 'S�.
Q
t
TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS
"-760
CITY & ZIP 7
EXISTING
4
•�
_7 ? —T (�
PHONC0
-
BUILT-UP ROOF ❑
LICENSE
NUMBER 10`0177
ASPHALT SHINGLES ❑ 9
WOOD SHAKES G�
LICENSE CONTRACTORS DECLARATION
I hereby affirm that 1 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
l
effect.
6
WOOD SHINGLES ZS
❑
License Clea Lie Nu
/�
_ ^
OTHER (SPECIFY) ❑
Data Contract
OWNER-BUILDER D RATION
PROPOSED
I hereby affirm that I em exempt from the Centradoes 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 Ilcensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (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 SHINGLES
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 ($50() .):
WOOD SHAKES
W ❑
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
sionsCode: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the building or improvement
is sold within one year of completion, the owner-builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sac. ,B & P. C. for this reason
Owner Date
q PLICATION DATE.
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
'.
I hereby affirm under penalty of perjury one n the following declaration:
for
❑ have entl will maintain a Certificate of Consent to sell - insure for Workers Compensation,
Building
Lb
eeprovided for by Section 3700 of the Labor Code, for the performance of the work for which this Q
of
permit Is Issued. F9
6 21 DI'(1T
11 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
RC{I D
/$
/�y/7
$eISR11C
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers,,-(v (
I/I
Total
Campenaetlonclncupr nce c rrler antl P y number re: c.0 ,
(- l,lri _
/'
PERMTAUTHORIZATION
DATE
Carrier StaF PoucyNd�734`f's��'°
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
^i'
(This section need not be completed If the permit Is for one hundred dollar. ($100) or less.)
G
��
I certify that in the performance of the work for which this permit is Issued, I shall not employ
any person In any mannor so as to become subject to the Workers' Compensation Laws of Cali-
All roots Shall be inspected prior to any roofing material being
forma.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, l 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 with all non point
P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must fohhwiN 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 verings to cl "C" or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for In-
spection purposes.
yA l agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against mid City in consequence
SI NATURE OF APPLICANT DA II
of the granting of this permit.
PRE - INSPECTION:
PLYWOOD: Ild
IN- PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPEcTNO BUIIDNG DEPAR . IENT
PRIOR TO ISSUANCE OF PEP NQ T AND NSPECION ..
1. P er [o pez it iss at ce, ypu must a,ee to compiv with U.B.C. st neares and ma ufac^ ea sec's
an reroofing.
2. New roof coverings shall not be auolied without first obtaining all inspection and writ•.ea acproval
from the building i==-.or. A final insce =ion and approval shall be obtained from &.e building
i=ec,or when the reroofing is camoleted.
3. All types of roof shall be inre = :ed prior to any roof being ins�alled.
4. In order to re'_cive a final, You must complete steps 1, 2, and 3.
1,) P.c4rMecdon or tr_r off aoeroval.
2.) In progress inspection approval.
3.) Final inspec-doa approval.
a.) Operacle smoke detector ve"u=ticn
• b.) Spark are_stor installation
5.. If plywood is installed, a plywood nail inrecapa is required-
Ii If stay roof is applied without first obtaining an ��pn, you will be required to remove all ne:v
material down to the sheathing and a building itt �e or will lore all sheathing at that time.
1VE UNDERSTAND TEE ABO`1E POLICY ON REROOFNG P_ND WILL COMPLY WITH Tr' ^-
POLICY
•
HOivEOWN+cRS NAME.
ADDRESSS
REROOFING COMPANY NAb1
APPLICANTS SIGNATURE:
CITY OF CUPERTNO
BUILDING DEPARTMENT
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