R-5396 NUMBAPPLICATION FOR CITY OF CUPERTINO
RR- 5396
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/0` T �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
TVES ❑ If yes-I understand that a Class A
NAME roof assembly Is required.
/ NO Initial LC.B.O,q
ADDRESS _ EXISTING ROOF CO ERIN
PHONE C�L�J�J NUMBER OF EXISTING COVERINGS
CONTRACTS"
i 11 R7 i T-f/) / / •/1 / ,�YJf /1 SIE TO BE REMOVED TO BE RETAINED
NAME VV fi.((Jl[L[J�[
ADDRESS '�/C/ /i n . ��n �, TYPE OF ROOF COVERING
CITY&ZIP C�L.L�/c-�C_'l
4?. -2 77Q EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
Licens Cles 4213119 UWOOD SHINGLESc.Numbs 7 u ❑
HER(SPECIFY) ❑
Date Contractor6!A42740
OWNER-BUILDER DECLARATION P p D P41
I hereby affirm that I am 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 p qp
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the11 UP OOF p� „rj l7❑
applicant for such permit to Ole a signed statement that he Is licensed pursuant to the provisions 1 �Nil' of the Contractor's License Law(Chapter 9(commencing with Section 7000)at Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged A P $HI S NI t❑
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($500).1: WOOD$HAK�$y & v
❑I,as owner of the property,or my employees with wages as their sola compensation,will do ❑
the work,and the structure is not Intended or Offered for sale(Sec.7044,Business and Profes-
sionsCode: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.It,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.).
❑1,as owner of the property,em 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 tontractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby allirm under penalty of perjury one of the following declaration:
❑Ihave ed fort $actimaintain 3700 of theicate bof Consent th Performa for Worker's Compensetlon, Building
ee provltletl for by Section 3]00 of the Labor Code,for the Performance of the work for which this ` / V lU//
pe m .a le:ueIf Seismic
I have antl will maintain Workers Compensation Insurance,as required by Section 3700 of
th or Code,for the performance of the rk for which this permit is Issued.My Works s
Compens n aura a yertl tl Polity n mbar are: / —r - Total
Carrier s,GQ Policy No. / PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' /
COMPENSATION INSURANCE
(This section need not be completed If the permit I$for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not ampIcy
any person In any anner so as to become ject to the Workers' ompensatlon Laws Of 'ell- All roofs shall a inspected prior to any roofing material being
fornia. �/ installed. If a roof is installed without first obtaining an
Data`0, Q-7 Appllcen inspection,I agree to remove all new materials for inspection.
subjecttothe WorrkersTO s'Com 11,
eon prrovisions doff thel`a oro Code,yolu musculo thwhoullth comp) Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, y comply 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 ordinance:and stale laws relating to building conslrucllon.ane roof COVer10 sto be class"C"gr better.
hereby authorize representatives of this tiry to anter upon the above-mentioned property for in-
spection purposes. /O�/
97
(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. SIGNAT OF APPLI ANT DAT
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 THE CITY OF CUPERTIPiO BUILDDIG DEPART`+FENT
PRIOR TO ISSUANCE OF PERMIT ,kN-D NS?ECTION PILASE.
1. Prior [o pe mit issuance, you must 3--e to comoly wr„
ith U.B.C. s .dards and %nufar.�ea sec's
on re:cof[ng.
2. New roof coverings shall not be acolied without first obtaining all inspecion =d :vrinen approval
from the building inspector. A final inspection and approval shall be obtained from the building
insuector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you Must complete steps 1, 2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
S. If plywood is installed,a plywood nail inrection is required
6. If any roof is applied without first obtaining an inspection, you will be required to remove all ne:v
material down to the sheathing and a building inspector will ince_:all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOnFi'NC P*+U WILL COMPLY W=i TnL
POLICY
HOMEOWNERS NAME:
2
ADDRESS” ' n
REROOFING COMPANY NAME: (a "
APPLICANTS SIGNATURE:
CITY OF CUPERTNO
BUILDNG DEPART\i[ENT
•
Reroo U\vinw6rd