R-5266 PERMIT R• 5266
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-322$ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
1110 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
NAME �.Q��/7�� YES ❑ It yes s I assembly
is req that a Class A
roof assembly Is understand
thatt
� NO Initial I.C.B.O.11
ADDRESS— /69q—
DDRESS /6 9q— "RfS lei EXISTING ROOF COVERING
PHONE D NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /�/
NAME P/l i CGC/ S�.�f+� �y/� TO BE REMOVEDy TO BE RETAINED
ADDRESS�• Z .Gla/�e(� EXISTING TYPE OF ROOF COVERING
/
CITY BZIP /
D
PHON 6p — Z Z3 BUILT-UP ROOF ❑
f LICENSE S
NUMBER ASPHALT SHINGLES ❑ J S
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter (commencing with Section WOOD SHAKES
]000)of Division 3 01 the Business and Professions Code,and myy license Is In lull lone and
effect. - ////���� -5 5 C WOOD SHINGLES
License Class Lic.Number `• I 7 3 p ❑�
Date-r' 9 Convector OTHER(SPECIFY) p W b
OWNER.BUILDER DECLAR N PROPOSED Ap 5 RECrD
hereby affirm that am exempt vom the Convector's U ansa Law for the lallowing reason. 11R I�
(Sec.70315,Business and Prolesslons Cade'.'Any dty r county which requires a permit to `fit a�
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑tHt II�Q
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions Ur
of the Contractor's License Law(Chapter 9(command ng with Section 7000)of Division 3 of the CI
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 live hundred dollars(5500)J: WOOD SHAKES ❑
[DI,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 Prof ul-
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ /V
Improves thereon,and who does such work himself or through his own employees,provided that �d
such Improvements are not Intended or offered for sale.If,however,the building or Improvement r✓
Is sold within one year of completion,the owner-builder will have the burden at proving that he did OTHER(SPECIFY) IR
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 Coda: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 contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. .B 8 P.C.for Nle reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury One 01 the following declaration: kill
1 have and will maintain a Certificate of Consent to sell-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 ^ p
permit Is Issued. �� X7 O •06 ) $eISmIC
7
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of GG Cl �/�/
the Labor CoIf for ih pada///mance of the work for which this permit Is Issued.My Workers Total _/7 8
Compensation Ipsareer antl P.gMui number are:
Carrier U\ Y'y TE OFEXEMPTIO FROMNo.� PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed If the permit Is for one hundred dollars(3100)or lass.)
I certify that In the performance of Na work for w la permit Is hall 1 shall not employ
any parson In any manner so as to become subje o e work re'compensation Laws of Cali- All roofs shall be inspected prior to any roofing material g
torrid. ' " c installed. If a roof is installed without first obtaining an
Date 41"1
�1 /7 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,liter making this Ceal' le of Exemption, u should become
subject to the Workers'Compensation provisions oft abor Code,you must lorthwithwmply App: t understands and will comply with all non point
with such provisions or this permit shall be deemed oked. S Fee regulations.
I certify that l have read this application antl e1di at the above Information is correct.)agree I
to comply with all city and county ordinances and state laws raising to building construction,and II too coverin sto be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in-
spection purposes. ��J�
(We)agree to Sava,Indamnlly and keep harmless the City of Cupertino against II8011ilies,
judgments,caste and expenses which may In any way accrue against said City In consequence _9FGNATUP#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 CUPERTINO BUILDLVG DEPAR—INIENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must a;ee to comply with U.B.C. standards and manufac:urea spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
tion and approval shall be obtained from the building
from the building inspector. A final inspe
inspector when the reroofing is completed.
3. Ali 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:ci==_ion or tear off apnrpval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. if plywood is installed,a plywood nail inspec ion 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 inspect all sheathing at that time.
%VE UNDER.STADID TEE ABOVE POLICY ON REROOFING AND WILL CON�LY WfI'ri Tri
POLICY
HOMEOWNERS NAME:
ADDRESS"'
REROOFD IG COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPART'M NT
•
Rercoflwimvord