R-5609 PERMITA
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 6 0 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
lgglRESIDENTIAL COMMERCIAL OTHER
OWNER%, - HAZARDOUS FIRE AREA
l/%�'/)��, VES E] If yes—I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.a
ADDRESS EXISTING ROOF COVERING
PHONE 62
NUMBER OF EXISTING COVERINGS C>AJG
CONTRAC R' /
TO BE REMOVED ON TO BE RETAINED
NAME
ADDRESS /-p��- TYPE OF ROOF COVERING
clrvazlP Cis+ i!CJ EXISTING
PHONES BUILT-UP ROOF
LICENSE / rj
NUMBER ASPHALT SHI J IES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHg,)(ES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and ddU
effect, _ W00/7 19ISHI LE4 �'C ❑ -
Licens Class Lic.Number y(,A (/
OTHER(SPEGIF ❑
Date Contractor
OWNER-BUILDER ECILkRATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 �1�\
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(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($501
❑ WOOD SHAKESl,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-
sions Code: The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
or
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 a Id within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulla or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contraning with licensed contractors to construct
the project(SBC.7044,Business and Professions Cede:The Contractors License LBW 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.
[II am exempt under Sec. ,B a P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
ably affirm under penalty of perjury one of the following declaration:
have end will maintain a Certificate of Consent to self-Insure for Worker's Compensation, / s «� Buildinb r
as r ied for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Coda,for the performance of the work for which this permit is Issued.My Workers Total
-the
Insurance car entl P number are: ' �����ss ,.x
Carrier���� Policy No. Ij•7 PERMIT AUTHORIZATIONDATE
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.)
1 certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensallon Laws of Cell- All roofs shall be inspected prior to any rotting m being
form's. erial installed. If a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove all new materials for inspection.
NOT CE APPLIANT. of Exemption,yoshoul
subject to theOWorrkereCCompensation
rrovisions of thtelcate Labor Code,you must fOthwithbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked. source reciAlations.
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 I cori gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentionad property for In. i/ 1
spection purposes. , Y
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs end expenses which may In any way accrue against sold City In consequence SIGNATURE OPA&PLICANT DATE
of the granting of this permit.
RE-INSPECTION: PLYWOOD: 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
w
SUBIECT: REROOFING POLICY FOR Tri CITY OF CLTPERTNO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PIL-� E.
e to comply with U.B.C. standards and manufacasrers sec's
I. Prior to permit issuance, you mus a;e
on rercoftne.
2. New roof coverings shall not be applied without first obtaining all inscection and write.^t approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is camoleted.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you mu_n complete steps 1,2, and 3.
1,) Preinscection or tear off approv„1.
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 inrection 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 in=e_t all sheathing at that time.
E UNDERSTAND THE ABOVE POLICY ON REROOFING PND WILL CO:vfPLY WITH Tri
W
POLICY
HOiv1EOWNERS NAME:
ADDRESS:`
REROOFu NG COMPANY NAME: 1
APPLIC�` I S SIGNATURE: /
CITY OF CUPERTINO
BUILDNG DEPARTMENT
w
Reroof/winword