R-5682 APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIRR- 5682
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /� �(/) ///
/� ✓ �� - �� RESIDENTIAL � COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
p YES ❑ If yes—I understand that a Class A
NAN/ / roof assembly is required.
'`� may/ NO _ Initial I.C.B.O.W
ADDRESS�7 7 =W��A ��A' EXISTING ROOF COVERING
PHONE �J NUMBER OF EXISTING COVERINGS
CONTRACTOR'S p
NAME r TO BE REMOVED�=BE RETAINED
• ADDRESS /J p �/ ,( TYPE OF ROOF COVERIN
CITY&ZIPS 2 x^'����//l� "' t/ �-�
• C/�!/� n EXISTING
,V PHONEEl(r77��" r 7 BUILT-UP ROOF
NIUMBER J /---7 y— ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensee under provisions of e,and B(commencing with Section WOOD SHAKES
]000)of Division 3 0f Business and Professions Coda,end my license is In lull force and
.neat. �-3 y H� WOOD SHINGLES ❑
License Class / Lid.Number J
Date Contra or OTHER(SPECIFY) El
OWNER-RI ILDERD CLARATION PROPOSED P A I I)
I hereby affirm that I am exempt from the Contractor's License Lew 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 118 'D ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ���"`�¶ O RE1n,
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Divislon 3 of the ,x�• CP/
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT GLES 1
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ,r{IfII'Y,}IL,'c�r (zu�EHtIN' �fer�T.✓/fir
e civil penalty of not more than five hundred dollars($500).): WOOD 5` _tie ❑
❑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.
Bions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,pointed that
such improvements are not intended or offered for sale.If,however,the building or improvement
is sold within one year of temptation,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 bulltls or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. 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:
❑I have and will maintain a Certificate 01 Consent to sell-Insure for Worker's Compensation, Build
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ��/} 7 7d�A• �jl SgIS C
1, ❑I haverZ
n Worker5C mp Bollen Insurance,as required by Section 3700 of CJ C/ V v
3
the Labor C .dor once of rk for which this permit is Issued.My Worker's
Compenseticar' r antl P y mbar are: Total
/ i
Carrier Policy N. Z2e PER IT AUTHORIZATION DATE-
CERTIFICATE OF EXIAAPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O 71
a
(This section need not be completed If the permit Is for one hundred dollars($100)or loss.) 7
1 comm,that in the performance of the work for which this permit is Issued,I shall not employ le
any person in any manner so as to become subject to the workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing matEii,ial being
forma. - installed. If a roof is installed withoutfirst obtat Ing 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 became Applicant understands and om I with all 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. $Our7z��
I certify that I have react this application and stale that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and roofIBS ,o better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
epecli m purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino egalnnst Ilabilitles,
judgments,casts and expenses which may In any way accrue against said City in consequenceE ICA DATE
• of the granting of this Permit.
PRE-INSPECTION: PLYWOOD: -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
• R TI c CITE 'OF CLrERTI: 0 BLTLDDiG DEPA.Ri LEN.i
SUBJECT. REROOFING POLICY FOR _
PRIOR TO ISSUANCE OF PE?'�'g i AND 24SPE 'Z ION PFLASE.
1. Prior to permit issuance, you must a;ee ro comply with U.H.C. standards and nanufcc-sea sec's
an
on rercoitng.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final in uec:ion and approval shall be °brained from the building
insrec cr when the re-coring is comoleled.
3. All types of roof shall be inspec'.d prior to any roof being insalled
4. In order to re^_cive a final,you must complete reps 1,2, and 3.
1,) P:einscecdon or tear off approval.
2.) In progress inspection aoproval.
3.) Final inspection approval.
a.) Operable smoke detector ver ncatian
• b.) Spark arrestor ins'allation
5. . If plywood is installed,a plywood nail inspection is require"_
6. If any roof is allied without first obtainin an tttsce nn0. You will be required to remove all new
material down to the shcthing and a building inspe for will incl sheathing at that time.
WUNDE?.STAND TI.,: ABOVE POLICY ON RERCO t G AND-WILL COMPLY WIT1
E 1 THE
POLICY
HOMEOWNERS NAME:
ADDRESS: `
REROOFING COlb(PANY NAME:
APPLICANTS SIGNATURE:
CIT[OF CUPERTNO
BUILDING DE?ARTLMENT
Reroaflwimvtird