R-5698 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5698
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME L' real assembly is required.
n NO Initial I.C.B.O.q
ADDRESS ����rrCC�77&� 1U•`b EXISTING ROOF CO1 RING
ft—
PHONE y V NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS � C TYPE OF ROOF COVERING
CITY a nP EXISTING
(�
PHONE \ri�V %\Np BUILT-UP ROOF ❑
LICENSE
NUMBER J O ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that em licensed under provisions of Chapter 9(commandng with Sect WOOD SHAKES ❑ l�
7000)of Division 3 Of the Business and Professions Code,and my license is In full force en
effect. _ WOOD SHINGLES pp��k y s
License Class Lia Numbar P �$ Y
Q D " ER(SPECIFY) LJi
DateOWNER-Bontre UILDER
6 JUL _
OWNER-the Conn DEC's License
P D �
hereby affirm that 1 am exempt from the Contractor's License Lew for the following reason.
(Sec.70315,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,to file signed statement
any structure,prior to Its Issuance,also requires the ILT-UP ROOF C17Y VI' (�
applicant for each permit to file a signed statement that he Is licensedactio pursuant l to the provisions r
of the Contractor's License Law(Chapter S(commencing with Section 7000)of Division 3 of the HI�NQ
' ex
Business tio end violation of Code)or that he Is exempt therefrom and the basso for the scantalleged ASPHALT SHINGLES
exemption.pen.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10
e civil penalty a no more than live my
dollars(h wag 8 WOOD SHAKES
❑I,as owner o the property,t I to ded employees with wages as their Bole compensation.will s- ❑
the work,and the structure is not Intended ores not
for sale n ow ero f Business and Profbuilds
or Code:thereon,
Contractor's License Lew does s eat apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work ed for or through hos own employees,improvement that ❑
such improvements are not intended or offered for sofa.If,however,the en of pr or proving
Is notsold bullwithinor
year of for purpose
sthe owner-builder will have the burden of proving that he tlltl OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contract)ng with licensed contractors to construct
the project(Sec,7044,Business and Professions Coda:The Contractor's 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 Sac. ,B 6 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 e
' ❑I have and will maintain a Certificate of Consent to selftinsure for Worker's Compensation, Building L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is have
anIssued. Seismic
-11 have and will themaintainrt Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance 01 the work for waste this permil is issued.My Workers �(�\
Compense'o Ina'��nce^�caxr'er entlP Ic number are: ` �'�— - 5 g V Total
Carrier ���t` =_ Policy No. �\��` PERMITAUTHORIZAT N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed It the permit is for one huntlre tlollers($100)or less.)
1 certify that In the pedormanca of the w if for which Is permit Is sue shall not employ
any person In any manner so as m become jet o the ars c Mon Laws of cell- All roofs shall be inspected prior to any roofing material being
fermi Qyc���. installed. If a roof is installed without first obtaining an
Date�U— Applicant inspection,I agree to remove all new materials for inspection.
subject t.EtheOWorrkers'Compensation rrovsionis of thecate of Labor Code,you
houldbecome Applicant understands and will comply with all non point
p p you must I thwite compty
with such provisions or This permit shell be deemed revoked. SO a regulations. -
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,antl All O CO erin be S' better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spoctoon purposes. `
.(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
oltnegranungmeispermit. SIGNAT RE OF APPLICANT DAE
• 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
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SUBJECT: REROOFi IG POLICY FOR TrF CITY 'OF CUPERTINO BUILDRNG DEPP.R,lENT
PRIOR TO ISSUA.�ICE T OF PERM AIND D'SPECTION PHASE.
e, you must agree to comply with U.S.C. standards and manufacrure:s sec's
1. Pilar to permit issuanc
on re:cofrng.
2. New roof cove ngs shall not be applied without first obtaining all in vection and wriren acereval
from the building in_�r_':or. A final in_�e tan and approval shall be obtained -Front the building
inspector when the reroofing is completed.
3. All'types of roof shall be inspected prior to any roof being installed.
4. In order to rr_elve a final,you Musa complete steps 1,2, and 3.
1,) P:einsr_don or tear off app royal.
2.) In progress inspection approval.
3.) Final inspr_tion approval.
a.) Operable smoke de,--*or ver n(=ticn
Ab.) Spark arsor installation
5. If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without first obtaimna an inspecnpn. You will be regttire3 to remove all new
material down to the e shthing and a builtling ittscr_.or will inspect all sheathing at that time.
WE UNDERSTADID Tia ABOVE POLICY ON REROOFING AND WILL COMPLY WITFr THE
POLICY
HOMEOWNERS NAME:
ADDRESS%`
REROOFING COb1PANYNA!vfE:
APPLICA`tTS SIGNATURE:
CITE OF CUPERTINO
BUILDNG DEPARTNIENT
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