R-5661 ERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5661
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 ` /
leobRESIDENTIAL v COMMERCIAL OTHER
OWNER'SC ��...yy���-�.�j• HAZARDOUS FIRE AREA��I l
YES yes—I understand ftI a Class A
NAME roof assembly is required.
NO ❑ Initial- I.C.B.O.k
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC 'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS t TYPE OF ROOF COVERING
CITY a ZIP EXISTING
I
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)o1 Division 3 of the Business and Professions Code,and my license is In full force and
effect.
WOOD SHINGLES ❑
Licansa a Lic.Number
DaContrtor '
OTHER(SPECIFY) Elte CI sac
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 file a signed statement that he Is licensed pursuant to the provisions
. of the Contractors 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 , G
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($501 WOOD.SHAKES
C]1,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 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.ll,however,the building or Improvement
is sold within one year of completloq the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ n I q
I,as owner of the property,am exclusively contracting with licensed contractors to yLRAt $.r
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew tloes 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
01 am exempt
)Ilcer Sec.pursuant to the Contractor's License t.ew. JUK�0 P'D PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C. rrrdD7 6
Owner Date
WORKER'S COMPENSATION DECLARATION I I r Qi- ARBLICATION DATE VALUATION PERMIT FEE
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
wn
as provided Is for by Section 3700 Of the Labor Code,IOr the performance of the work for which this
permit is Issued.and I /VAII 'y"/I I / Seismic
f ❑ have end will maintain WoCdn
pensatlon Insurance,as required by Section 3700 of
„the LP Dor pQOe,(fir the erlormwork for which this permit is issued.My Workers
Com ansa n l uranc cerrlarumber are: Tota
�S -9'1
Carrier "4' a Policy No. PERMIT AUTHORI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) M
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 Law.of Cell- All fs shall be inspecte - r to any roofing material being
forms. 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 llcant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P P Y
with such provisions or this permit shafte deemed revoked. soul reg Ulations.
I certify that l have read this application and state that the above information is corracL l agree
to comply with all city and ceunry ordinances and state laws relating to building construction,and LLAf coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. - p
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, /
ludgments,costs and expenses which may in any way accrue against said City in consequence SIGNATU E 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBIrCT: REROOFING POLICY FOR TI-E cl cf tOON UPE TNO BLTLDLVG DEPART;LENT
PRIOR TO ISSUANCE OF PEP,T1 AND INSPEr I
1. Prior to pe.mit issuanca, you mus. a;ea to comply with U.B.C. standards and manuftcuers step's
on reroofing.
2. New roof coverings shall not be aoolied without first obtaining all inscec.icn and wrinen approval
from the building in fir_:or. A final in�ec:ion and approval shall be obtained -from the building
ins,oector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
Y 4. In order to re^_cive a final,you mu_a complete steps 1, 2, and 3.
1,) P:einspecdoa or tear cff approrl.
2.) In progress in pection approval.
3.) Final insperSon approval_
a.) Operable smoke dete_or verification
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and abuilding inspr or:viil Imre_.all sheathing at that time.
NE UNDERSTAND Trr ABOVE POLICY ON REROOFING PND WILL CO vfPLY WITH Tr'
POLICY
HOMEOWNERS NAME:
' ADDRESS:
t REROOFING COMPANY NAME:
APor IC ANTS SIGNATURE:
CI i Y OF CUPERTINO
BUILDING DEPARTZ ENT
•
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