R-5673 PERMIT R_
5673 .
APPLICATION FOR NUMBER
R-CITY OF CUPERTINO U
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
n
IOC4 kit � LC RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME A n .of
assembly is required.
NO ❑ Initial I.C.B.O.H
ADDRESS las so &411 AV' g EXISTING F COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S W� L �(y� \/ (�
NAME t• lips\ ��f.. TO BE REMOVED TO BE RETAINED
1�
.ADDRESS TYPE OF ROOF COVERING
Q �p -
'i a ZIP V '� ' p�1� Z1 I � ��n Din— EXISTING
,PHONE –7 4"f /—!V!t:1c;) BUILT-UP ROOFLICENSE
❑ ``
INUM13ER LICE ASPHALT SHINGLES El !l
SED CONTRACTORS 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 Is In full force and G}
affect. WOOD SHINGLES ❑
License Class�' Lic.Number 2 z
oate Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's 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 IL�JN
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 t'��g�,,
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES JuI�'1�7 'fl
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to YY
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD.SHAKES
CITY OF u�' YEHiINO-
the work,and the structure is not Intended or offered for sale Sea.7044,Business and Profes-
sionsCode: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 awn 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-builder will have the bu rden 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 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 ?NL Q)
with a conireclor(s)tic sed p ant to me Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. 1
❑I am exeopt
mpt er S ,B&P.C.for this reason
Oyner 42� - Date APPLICATION DATE VALUATION PERMIT FEE
ORKER'S OMPENSATION DECLARATION
( I hereby affirm u or malty of perjury one of the following declaration: �(/L�
L]I have antl will Intain a Certificate of Consent to self-Insure for Worker's Compensation, Building 4/7,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this \ O, / p�
permit is issued.and v�� Seismic /.�
i ❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700's
the Labor Code,forme performance of me work for which this permit is Issued.My Worker's so
�Cempensa9 sur ce car'er antl Polley number are: /� Total
Carrier Policy Noti0,, PERMIT AUTHORIZATION DATE
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit is for one hundred dollars($100)or IessJ (�
I 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'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
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: If,alter making this Certificate of Exemption,you should become Applicant Lind stands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalit deemed revoked. sour
Ce fegUl (Dns.
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,and All roof C ings be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection 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
of the granting of this permit. S AT OF APPLItAT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR Tri CITY OF CUPERTINO BU�DLNG DEPAR71,1ENI
PP-TOR TO ISSUANCE OF PER+`lIT AND INSPE'C ION PHASE'
I. Prior to pe.mit issuance, you must 3,= to comply with U.B.C. standards and manufacn re:s sec's
on reroofing.
2. Nev roof coverings shall not be applied without first obtaining all inspection and %mizzen approval
from the building inspe_:or. A f al inspecnon and approval shall be obtained from tl e building
inspector when the reroofing is ccmole:ed
3. All types of roof shall be inspected prior to any roof being instilled
4. In order to receive a final,you mt_a complete reps 1,2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Finalinspecioa approval
a.) Operable smoke dete^_tor verification
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inspection is required.
be required to remove all new
6. If any roof is applied without first obtaining an ince-ion, you will
material down to the sheathing and a building tnspr-'or wu Msp all sheathing at that time.
m
%VE UNDERSTAND TI-E ABOVE POLICY ON REROOFING AND WILL CO ViPLY =11 Tn.
POLICY
EO&CEOWNERS NAME-
C N
ADDRESS;
REROOFING COMPANY NAME: VA U
APPLICANTS ANTS SIGNATURE:
CIT!OF CUPERTINO
BUILDING DEPARTMENT
•
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