R-5649 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5649
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1BO DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS/ / // /
O ( 3 rCY-�+C xi _ RESIDENTIAL Z
COMMERCIAL ' OTHER
OWNER'S HAZARDOUS FIRE AREA
YES If yes-I undersland that a Class A
NAME � roof assembly is required.
NO ❑ Initial LC.B.O.Ir
ADDRESS �� S C G� L �� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ///�� '
NAME
�GP�r/,4 TO BE REMOVED TO BE RETAINED
ADDRESS '.y 9 �l� rJ� TYPE OF ROOF COVERING
CITY&ZIP d- �7`
EXISTING _
PHONE / 7 r'J - y / 7 BUILT-UP ROOF ❑
LICENSE
NUMBER -7 3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 01 Business and Prafesslons Code,and my license Is In full force and
affect. / / (';
_ 7 SZLE -73� WOOD SHINGLES ❑
License Cles Lia Number l
Date_ -10 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDERDECLAR ON PROPOSED
I hereby affirm that I am exempt from the Contractor's ense Law for the fallowing 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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractors License Law(Chapter B(commando,with Section 70001 of Division 3 of the
El
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($51 WOOD SHAKES E]❑I,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 sole(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 sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builderwlll have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construuqq A
[7 n
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does hot PROVIDE I.C.B.O.REPORT NO. C90
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant t0 the Contractors License Lew. C.for this REEBOVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P. jUN
Owner Dere ptppLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION LII I Ur tyy� i+
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 Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
1 permit is issued. /y 7 a6 $elSrrllC
❑I have end will eI t Worker' pensetlon Insurance,as required by Section 3700 of D S
' -the Labor he pe r no Of t a work for which this permit Is Issued.My Worker's
Componset on In rents rrler d Policy number are: ,Ip- Total
f Cancer P ` Policy No. �^ PERMIT TION DATE
CERTIFICATE OF EMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[
(This section need not be completed If the permit Is for one hundred dollars S1 00)or less)
I certify that in the performance of the work for which this permit Is Issued,t shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- 41F r ofs shall be inspected prior to any roofing material bei 6g
fornia. ns[ lied. If a roof is installed without first obtaining an
Date Applicant i action,I agre.1 1 remove all new materials for inspection.
ecome
subject CE TO
Workers'Compensation prolvisionls oftheLabor Code,cate of Exemption,
lu must forthwith ou lbcomply Ap nt understands and will comply with all non point
with such provisions or this permit shaftdeemed revoked. S Urce egulations.
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 II roof Tv rings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- yyy'//
spectlon purposes. 6 — / s�/7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, / /
• judgments,core expenses end which they In any way accrue against said Gly in—sequence
of the granting of thiand permit. QV15NAT99E OFAPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _ _
SUBJECT: REROOFING POLICY FOR THE CITE OF CUPERTINO BUILDD;G DEPAR7,,IEN7
PRIOR TO ISSUANCE OF PER:1IIT AND INSPECTION PHASE
1. Prior to permit issuance, you must a,ee to comply with U.B.C. standards and rm[[ufarses tee's
on re:cofing.
2. New roof coverings shall not be applied without first obtaining all in_,ecion and written acercval
from the building ince-_:or. A final ins-e-tion and aooroval shall be obtained from the building
inspector when the reroofing is=mulcted.
3. All types of roof shall be inspca-cA prior to any roof being installed.
4. In order to receive a final,you mu-R complete steps 1,2, and 3.
1,) Preinsze^_tion or tear of apprcvnl.
2.) In progress inspec:icn approval.
3.) Final inspection approval.
a.) Operable smoke dere=:or ve:incation
• b.) Spark are_-,or imsallation
5. If plywood is installed,a piywccd pail inspection is required.
6. If any roof is applied without first obmimn; an i'me=tlon, you will be required to remove all new
material down to the sheathing and a building inspector will inspe all sheathing at that time.
NE UNDERSTAND Teas. ABOVE POLICY ON REROOFI C AND WII L COL LY WITr' Tr;
POLICY
�A le i N
HOMEOWNERS NAME:tAME:
,G
p9 �E Q
P�DRESS: `-
REROOP'1NG COMPANYNAZAE: L"' SSflx�
APor IC AVMS SIGNATURE:
CITY OF CUPERTNO
BUILD NG DEPARTS(ENT
ReroofAvinwdrd