R-5646 PER
•APPLICATION FOR clrY of cuPERrINo
NUMBER R- 5646
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
3 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
G L/J 7� �D�G� VES ❑ If yeas I assembly
is req that a Class A
NAME ,71C-� root essemby is required.
!� NO Initial I.C.B.O.M
ADDRESS— ���5 £F/J�yG1e EXISTING ROOF COVERING
PHONE S'3 — NUMBER OF EXISTING COVERINGS I/
CONTRAC OR' /
duf}'L /!_G7C9,1�/�O • TO BE REMOVED TO BE RETAINED
NAME
ADDRESS /��� i/ 0�� ��� � r TYPE OF ROOF COVERING
CITY&ZIP� 7 !�/ EXISTING —/
PHONE -:? ���—�?-_Z2 - BUILT-UP ROOF �(
LICENSES ASPHALT SHINGLES ❑
NUMBER l
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensedunder provisions of Chapter 8(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business
and
and Professions Code,and my license is In lull forte and �
effect.
WOOD SHINGLES
License Class ✓�� Lic.Number �/
6.— f' —Lf '�-- oyr�,�6 OTHER(SPECIFY)
Date, Contractor
OWNERBUILDERD CLARA PROPOSED l
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
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions
. of the Contractor.License Law(Chapter g(commencing with Section]000)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
a civil penalty of not more Man five hundred dollars($501
1-]1.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 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,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
for Wo
have and will maintain 37a Certificate of Consent to performance
for Workers Compensation, H, I Building
asprovidedIS is for by Section 3700 of the Labor Code.for the pedormancaof the work for which this f
permit Is issued. S(/ Seismic
❑ have end will maintain Worker's Compensation the workfor Insurance,as required Is i by Section 3]00 of JUN 23 CO
the Labor Coda,for the performance of the work for which this permit Is issued,My Worker's
Compenaelb In�surnance cerrler and Policy number ere: Total
Carrier OC[�L/L .I/I ! �lq�)fi Policy No. Q1K017 Oc/ - CI RJt41TION DATE
CERTIFICATE OF E%EMP ON FROM WORKERS'
COMPENSATION INSURANCE N.C. /t/1
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) co
certify that in the performance of the work for wh' is permit Is Issued an not employ
any person In any manner so as to become subjec o th vers' ampans d aws of Calh All roofs shall be inspected prior to any roofing material being
lornia. installed. If a roof is installed without first obtaining an
Date b 3- Apprpam inspection.I agree to remove all new materials for inspection.
u should become
subject t.theOWorrkera Compensatl n proNOT CE APPLIANT. it,aftrivisionis ofthecnilcate Labor Coxa umus fonhivith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city end county ordinances and state laws relating to building construction,and All comply with all city and county ordinance.entltate laws relating to building construction,antl ringS O b C' ��C"or better
O b C' �� or better
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(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 mid City in consequence
of the granting of this permit. S .IGNATURE OF LICANT 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: REROOFI,NIG POLICY FOR THE CITY OF CUPECTINO BUII.DL`;G DEF.AR HENT
PRIOR TO ISSUANCE OF PE:ZNaT AND INSPECTION D
ION ..A_—.
1. Prior to pe. r it issusnce, you must a>ee to comoly wilt U.B.C. s-andcrds and manufac7drers sec's
on re:coftng.
2. New roof coverings shall not be apolied without first obtaining all in-ection and %spirem approval
from the building in_�ecmr. A final in-�ecaon and aoeroval shall be obtained from the building
insoec:or when the rerccftng is camole:ed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must cpmple:e segs 1, 2, and 3.
1,) P:ei=c--:ion or tecr of aoeroval.
2.) In progress inspection approval.
3.) Final in_sperion aoeroval.
a.) Operable smoke de,.ec:or vertitcadon
• b.) Spark arestor insallation
5. . If plywood is installed,a plywood[tail inspec ion is required.
6. If any roof is applied without first obtaining an inspec ion, you will be required to remove all new
material down to the shcthing and a building inspe=or will in_spe•_:all sheathing at that time.
WE UNDERSTAND TIS ABOVE POLICY ON REROOFING P—ND WILL COMPLY WITIH Tri
POLICY
L:Oiv1EOWNE?.S NMA_vtE: --�
ADDRESS"'
oof/rl
REROOFuNIG CONEPANYNAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTNO
BUILDING DEPART,\AENT
•
Reroowinwdrd