R-5471 PERMIT R- 5471
APPLICATION FOR CITY OF CUPERT.INO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406) 777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL X_ COMMERCIAL OTHER
OWNER'S
�� /)� HAZARDOUS FIRE AREA
/ /,(`/ YES ❑ If yes—I understand that a Class A
NAME_ NO I roof assembly is re" initd.ial LC.B.O.#
ADDRESS � (�'/��//1� EXISTING ROOF COVERING
PHONE 5� / O L/ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'
CL.L.Q�✓ W /L/�Cd TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ���
TYPE OF ROOF COVERING
CITY&ZIP d� EXISTING p
PHONE <L4 o 69 BUILT-UP ROOF laor 4 'a
LICENSE C // `/ 2�
NUMBER 5s 7 3 b ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
U
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sec
� / YY OD SHAKES h
]000)of Division 3 of the Business and Professions Code,and my license is in full force to;
effect' COD SHINGLES
License Ciass U: Numbor
C -IETS�7J�I�U.a-YI
Date R(SPECIFY)o Contractor - - - - `Y
OWNER-BUILDER DECI-ARATildh 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 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 r 9(commencing
that it licensedctio pursuant to the provisions
of the Contractor's License Lew(Chapter 9 enttheh with Section 7000)pursuant
Division 3 of the /7/✓
• 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(5500).1: WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their safe compensation,will do
the work,and the structure Is not Intended or offered lar seta(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 sate.II,however,the building or Improvement /7 h
b
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) lL..�_..
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 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 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 of Consent to self-insure for Worker's Compensation, U/ Bulldln . nQ /`
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this p/ .�/r // L7
P
a Issued. �1/,j Seismic
eve end will maintain Worker's Compensation Insurance,as required by Section 3700 of
1h Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
'Compensation urs e c�`ner end Policy number are:
Carrier— ;T : �•'^-u-- Policy No.a 3S '�3Z PERMIT AUTHORIZATION AT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is issuetl.I shall not employ
any person Iverson n as to become subject to th orkers'CD sation Laws of Cali- All roofn shall ffe inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Appllcent inspection,I agree to remove all new materials for inspection.
NOTICE'TC,APPLICANT: If,ober making this Cartif/ ate of Exemption,you should become Applicant understands and WII
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply comply P Y Wlth all lion point
with such provisions or this permit shalGbe deemed revoked. source regulations.
I certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cov rings a Class" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities. i
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF PLICANT 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: RF-ROOFING POLICY FOR T'r..: CIT-ii'
l GY OF CDuE`T210 BMDDIG DEPP.R71EN+i
PRIOR TO ISSUANCE OF PERNNUT AND Di„P_CTION P.IAS-.
1. Prior to permit issuance, you must agree to comply tviuh U.B.C. standards and rnznufaccyrers sec's
on reroofing.
2. New roof coverings shall not be ouciied «itheut first obtaining all inspection and «Tinea accroval
from the.building inspector. A final inspecrlon and approval shall be obtained from uhe building
inrector 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 mu_R comole'steps 1,2, and 3.
1,) P:einscec:ioa or tear off approval.
2.) In progress it,—r t on approv 1.
3.) Final inspection approval.
a.) Ope able smoke de: :or verification
• b)
5, if plywood is installed, a plywood nail inspection is required.
6. If any roof is applied without firs obtaining an inspection, you will be required to remove all ne:v
mate al down to the sheathing and a building inspector Nvill inrr_':all sheathing at that time.
NVE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY %'Y= Tn-E
POLICY _
I:OivIEONW c.RrS NANIE:
ADDRESS.' `. /
REROOFING CODAPAN`IY NAME: ct �
APPLICANTS SIGNATURE:
CITY OF CUPERTIiO
BUILDING DEPAR"ItiBNT
•
Rerpof/Nvimvord