R-5545 APPLICATION FOR CITY OF CUPERTINo
NUMBER PERMIT
R- 5545
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS '
( K RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/,, i/ —rte LAIR
I / ,( VES ❑ If yes—assembly
is req that. Class A
NAME /mak /Ut- 1 Sn ��/ '�f ✓'t• cool assembly is required.
/ NO Initial— LC.B.O.k
ADDRESS I o I b l.x, To..e�oC'^ �� 9b!ZL EXISTING ROOF COVERING
PHO
CNE O Z �Q NUMBER OF EXISTING COVERINGS 1
ONTRA 'S TO BE REMOVED
/Qs—
Q OU �� TO BE RETAINED
NAME I`
ADDRESS z TYPE OF ROOF COVERING
CITYaZIP So Snv,Sosc' CA 9s /EXISTING
s PHONE.(o J -71 - 7 SOCA BUILT-UP ROOF
LICENSE
LISZ ! ASPHALT SHINGLES ❑
LICENSEDCONTRA ORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license la In full force and
effect. 39 WOOD SHINGLES
License Class _ Lia Number ❑
OTHER(SPECIFY) p ElDate Contra or f w
ER__ 11 ATION PROPOSED A ,
I hereby affirm that I am exempt from the Contract° License La for the following reason.
(Sec.7031.5,Business and Professions Code: Any c y or county hich requires a permit to
construct.alter,Improve.demolish,or repair any structu riort Issuance,also requires the BUILT-UP ROOF
apPacam for such permit o Ills a elgnetl statement that he nsed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the !jy
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Uh GtU
sicamoCode:
xption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
l penalty of not more than five hundred dollars($500).): WOOD SHAKES �t❑/N(J
I,as owner of the property,or my employees with wages as their sole compensation,will do
hrk,and the structure Is not Intended or offered for sale(Sac.7044,Business and Protes.
The Contractor's 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 sale.If,however,the building or improvement j
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) oOl I�
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 builds Or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B&P.C,or 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, Building
as provided for by Section 3700 OI the Labor Code,for the performance of the work for which this 7
permit is issued.and $BISRIIC
❑ have and will maintain Workers f the work
for Insurance,as requiredsu Section 3700 s �,
- ,the Labor Code.for the performance of the work for which this permit is Issued.My Workers /9
omTotal
Ceensatlon Insurenc�r�antl L�PoI�cy number ore P011cy No.Y"!�-��y'
1. V — PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' fin iff.
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit Is for one hundred dollars($100)or Ism.)
I certify that in the performance of the work for which this permit Is issued.I shall not employ
any person i ny m neer so as to becomes cReTBewmhe qm 9nsation La. of of. All roofs shall be Inspected prior to any roofing material being
°'nla. installed. If a roof is installed without first obtaining an
Data� APP cant inspection,I agree to remove all new materials for inspection.
subject lto the Workers'Comp°lnsaton provl ons of thefter flLab Code,you must°foinwlcl ithb omply Applicant understands and will comply with all non point
with such provisions or this permit shaiPbs d ed revo source regulations.
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 B ei5 class"Ci"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or In-
judgments,
purposes. .�
(We)agree to save,expenses
and keep harmless the City against
Cupertino against sequence
judgments costs and expanses which may In any way accrue against sold City In consequence
of the granting of this permit. �IGNATURB\OF APPLICANT ODATE
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: REROOFING POLICY FOR T11-1E CITY OF CUFER i1O BUILDL`+G DE?-RR7ME-N1
PRIOR TO ISSUANCE OF PE?`,II T AND li`'S?E`'TION PHASE.
1. Prior to permit issu=ce, you must a;= to comply pith U.B.C. standards and rn=LLlac-se;s spec's
on remoftng.
2. Ne•.v roof coverings shall not be applied without first obtaining all inspection and wrrten approval
from the building inspe -or. A fin tnscecnon and acorovni shall be cbmiaed from t e building
• ins-ce^.or when the reroofing is completed.
3. All types of roof shall be ins,-e=-.ed prior to any roof being installed.
4. In order to receive a final,You must complete steps 1,2, and 3.
e
1,) p:einspecticn or tecr off approval.
2.) In progress inspec ion at) rev'+1.
3.) Final in_me:.ion approval.
a.) Operable snoke del.--or verification
b.) Spar's arrestor insallation
• 5. . If plywood is installed,a plpwccd nail inspection 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 build' insvc,or will inspe=all sheathing at that time.
%VE UNDERSTA,ND TF= ABOVE POLICY ON REROOFING AND WII L COMPLY WITH Tri
POLICY
FOivfEO\VNERS NAME:
ADDRESS: \
nV
b
REROOFuIG COMPANY NAME: v
APPLICANT'S SIGNATURE:
CITE OF CUPERTNO
BUILDING DE?ART'NIENT
• Rercof/winward