R-5650 APPLICATION FOR CITY OF CUPERTINO
NU BR Res 5650
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-322$ PERMIT EXPIRES O WORK IS NOTSTARTEDOR
WITHIN S F DAYS S PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
AS BUILDING ADDRE)SS1
I �I -7"'I COLLI N I15 001lI 75r RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��^�sV'y^�,1L- YES E] If yes-I understand that a Class A
3✓
NAME T r �b roof assembly Is required.
�j NO Initial LC.B.O.k
ADDRESS a (o Lu xJ b 51nro �T$t 5T- EXISTING ROOF COVERING
PHONE a5`3 0 v 7-- NUMBER OF EXISTING COVERINGS
CONT
NAME \A: R) lI ���
V8 JQFrS TO BE REMOVED TO BE RETAINED d
NAME
ADDRESS 'T7�� �M �f�` A� 5T ��I�� TYPE OF ROOF COVERING
CITU&ZIP/�,� /'��/ •L EXISTING
PHONE �{o5rfl)_T) 3 7 b BUILT-UP ROOF ❑
LICENSE 57w M) ASPHALT SHINGLES
NUMBER .7 ! 1 El
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em Business
licensed under provisions of Chapter y(commencing In with Section WOOD SHAKES
]000)of Division 3 of the Business end Professions Code,and my license le In full force and a
effect.
WOOD SHINGLES f A ,
License Class Llc.Number D
Data me!
OTHER(SPECIFY) J(r,
OWNER-BUILBUILDER DECLARATION PROPOSED �0 C21
I hereby affirm that ow
am exempt from the Contractor's License Lew for the following reason. ^Item
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to y 17
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF UfL :UPEkTry
applicant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions Q
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 29
e civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code: 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 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 burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I.as owner of she 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 contractor(s)licensed pursuant to the Contractors Ucense taw. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 9 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 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldm /
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Iseuetl. —�
) l have and will the pert Worker's Compensation the work
Insurance,as required by Section 3700 s Se1SfT11C
11 N�fu
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compense n Insurance carrier end Policy number are: Total
Carrier Zr�l% IS - Policy No. f"""y� `� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) 1<7
I certify that in the performance of the work for which this permit Is Issued,1 shall not employ
any person in any manner so as to become subject to the W rare'CompenaetIon Laws of Cali- All roofs hall be inspected prior to any roofing malerial being
fornla. installed. If a roof is installed without first obtaining an
Dale ^�7 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWorrkers'Compensation
provisionls of then Labor Code,yocate of lu must forthwithcomplyApplicant understands and will comply with all non point
P P Y PY
with such provisions or this permit shell be tleematl revoketl. SOUfCe regulations.
Y' I certify that l have read this application and stale 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 COV Ings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. / Or;-A 7
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence SIGNATURE-OF APPLICANT DATE
of the granting of this permit.
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 CITY 'OF CUPERTINO BU"Q_DDiG DEPARTi IENfI
PRIOR TO ISSUANCE OF PERv11T AND NSPEC i ION P�LL.Sc.
, you must 3,,,e-_ to comoly with U.B.C. s andards and manuf
1. Poor to permit issuancecc-a ors sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all Inspection and winen approval
from the building inspr_':or. A final ins7,ec:ion and approval shall be cb dined from the building
inspector when the reroofing is camuie:ed.
3. All types of roof shall be inspected prior to any roof being installed
4. In order to receive a final,You mutt complete steps 1,2, and 3.
1,) Preinspe_doa or tear off aperpvrl.
2.) In progress in_-ecticn approval.
3.) Final insce_'.ioa approval.
• a.) Operable smoke det c:or veriucatien
b.) Spark arrestor insmilation
5. If plywood is installed,a plywood trail ince-son is required
.6. If any roof is applied without firs. obtaining an tnspecaon, You will be require3 to remove all new
mate ial down to the sheathing and a building ince-:or will inspect all sheathing at that time.
WE UNDE?,STAi`ID Tj-E ABOVE POLICY ON REROOFING PND WILL COMPLY WITH Tr^
POLICY
FOivfEOWNERS NAME:
`lt'� NSyC.u�Jl,SU1�u�t G�
ADDRESS"
REROOFING COMPANYNAME:
APPLICA41 S SIGNATURE: n
r CIT[OF CUPERTINO
BUILDING DEPARTMENT
Reroof/wimvdrd