R-5736 PERMIT R_ 5736
• APPLICATION FOR CITY OF CUPERTINO NUMBER
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 �p
"? 9 2 Co Bee K m01 T I. RESIDENTIAL COMMERCIAL OTHER
OWNER'S/^I 1 HAZARDOUS FIRE AREA
T/1 1 S O✓t TSI YES E] If yes-I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS 2 6 gle k A� EXISTING ROOF COVERING
L�
PHONE 14 2rNUMBER OF EXISTING COVERINGS
CONTRACTOR'S /� L
NAME
(fikl A I S S of IGC I`OQT�� KTO BE REMOVED I TO BE RETAINED
c
ADDRESS 2 2 (_; N Ga / yt e �S/ S TYPE OF ROOF COVERING
CITY aZIP EXISTING
PHONE +0 T r 6 ct -7 BUILT-UP ROOF ❑
NUM
eEa S Sal 3 Cp ASPHALT SHINGLES
LICENSEDD CONTRACTORS DECLARATION
hereby affirm that I em licensed antler provisions of Chapter a(commencing with Section WOOD SHAKES
f
7000)of Division 3 of the Business and Professions Code,and my license is in full lone and
effect' can SS 7'7,3(o WOOD SHINGLES
/
—10--9-7Contractor �lLic.Num
DateLicenseber OTHER(SPECIFY) ❑
Date ,BUIUDE
OWNERRDECLAR ON PROPOSED
• hereby affirm that em exempt from thethe Contractor's License Lew for the following reason. A z, '
(Sec.construct.
attar.
Business and Professions Code: Any city Or prior
Issuance,
requires a permit to 4L� , x.,
applicant for
Improve,demoto file signedrepair statement that
prior toItsIssuance,els ore quires the BUILT-UP ROOF a-- LHJ!-9
applicant for etch permit a Ills a signed statement that ha Is licensed pursuant to the provisions 417bil
of the Contractor's License Law )or that BIsex'commencing with Seldom 7000)of Division 3 0l the -0V O
• Business and violation of Code)or that he la exempt therefrom and the basis for the alleged ASPHALT SHINC�h
exemption.Any violationof Section 7031r byany applicant for a permit subjects the applicant to 9�
e civil penalty of not more than five hundred dollars($500).): U/� 4
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Lar-� ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES E] `
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.It,however,the building or Improvement M�jlr
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.). 1cJ�0 q
❑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 Lew 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 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 o1 Consent to aelf-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
permit l!'Josued. 1
eve and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier S40l :F:;,% 0`1"ll Policy No.`�J --17 7�'Z PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
O(This section need not be completed It the permit Is for One hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensadan Laws of Cab- All roofs shall be inspected prior to an roofing star al sing
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: ll,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
dubject 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 stets 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon ,e _/ ��H / n1 . _
(We)agree s save,Indemnify and keep harmless the Clry ai Cupertino against liabilities,ence C/p�{�(�6 �'-C ✓�
judgments,coats and expenses which may In any way accrue against Said City in consequence• SIGNATURE OF APPLICANT DATE al the granting of 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 _
\
— l- OFFICE COPY
SUEIvCT: REROOFuIG POLICY FOR T—,:E CITY OF CUPERTINO ELL-LDD:G DEP RT C`ii
PRICR TO ISSUANC=OF PERJ,[I \+\4-D DqSFECTION P�L=.SE•
1. Facr to pe.^it is=uanc'. veu ^es a,ee to cameiv «it_h U.E.C. s;aace:s and c .e'ece�ea -yeas
an rc cofing.
? New roof coverngs shall nor be acolied «ithcut first obtaining all ins;tc:ion an =,, ea aecrovai
from the building insper:or. A
final in�ec.ion and ocoroval stall be cbc.:neo ---,m the bu::ding
ince^or when the Te:cofms is comoieted.
3. All r;-pes of rcof shah be inspected Prior to day rcof ceing installed.
4, In tree:m receive a final.you=,,t complete steps 1, 2, and 3.
1,) P:eiase_dco or tear off aper0v2l.
2.) In progress in—
ection aporcv 1.
3.) Final in--,e---.;On approval.
• a.) Coe- ble snake der :or ve=firuon
5. If plywood is ns ailed a plywood nail ins;eraon is required
6. If any roof is aopiied without first obtaining an insertion you will be required to remove all new
ma[enal down to the sheathing and a building inspe:or w 11 ince_:all sheathing at that time.
%Vc -DEPS- ND I- p30VE POLICY ON RERCOFTNG p1� `HLZL CONCPLY W= Trr.
POLICY
SON -To ✓t
HONIEONticRS NAME:
01 $''L(o BCG 9 yKil N p
ADDpas S:
12en �t � SS4(NC-e
REROOFD IG CONfP-*N NAME:
poor ICA.`+1 S SIGNA—li-RE:
CIT! OF CUPERTINO
EUILDING DEPpR1\CENf
Reroogwinword