R 5188 PERMIT R_ 518 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 Rend - Lti
RESIDENTIAL COMMERCIAL OTHER
OWNERS it - HAZARDOUS FIRE AREA
I 1 1/ /��yp h YES ❑ If yes s I understand that. Class A
NAME (' WWW f7 .C�1J//,_� NO 14 root assembly is requires tial I.C.B.O.ri
ADDRESS 1119 '`�l�uh � MT.✓C EXISTING ROOF COVERING
t NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTO 'Sp^
NAME
L.r -ADD/ •'iY �O TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITYBZIP� ftq�nnu& ✓ 4JTycqn3 EI
STING
PHONE 46
BUILT-UP ROOF ❑
LICENSE 4136916 n z
NUMBER �—✓� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby Division
that I amus nes and
Profession of Chapter g(commencing with Section WOOD SHAKES El
7000)of by affix 3 of the tic Business end under
provisions
Code,and mycoolicense Is In full force and LJ
effect' q ) 1 WOOD SHINGLES
License Claes Llc.Number CJ
1D—
tOTHER(SPECIFY) 9
Date Conrector
OWNER-BUILDER DECLARATION PROPOSED 6
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 El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 8(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
e civil penalty of not more than five hundred dollars($500).1:
01,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-
slons 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 wl 11 have the burden of proving that he did OTHER(SPECIFY) El
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
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFG R.INSTALLATION SPECS.
El em exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, PAID . Zf � BUlding�_�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which Nle
permit Is issued.and. Seismic
t, ❑ have end will maintain Worker's Compensation which this as required by Section 3700 of EBY jj 4
the Labor Code,for the performance of the work for which this permit Is lasued.My Worker's uh(9 u 1S 'er9P Total
Compensation Insurance carrier and Policy number are: x7Sl�
Carrier Policy No. CI h (,{i,Ei $�� THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE l00)o
(This section need not be completed If the permit is for one hundred dollars($100)or lase.) 1f �•(`
I certify that In the performance of the work for which this permit ienpa
,I shall not employ
any person in any manner so as to become eu ct to the Workers'Canon Laws of call. All roofs shall be inspected prior to any roofing material being
fornix' //f installed. If a roof is installed without first obtaining an
Date/O- / _q( Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject l2the WorrkersE TO s'Compensetlon provisions ofthis ethteicate of Laborr Code,you must fothwlltlbecome
th 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.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All oof coverings 10 a c ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.spection
judgments,
purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
of the gran coats and expenses which may in any way accrue against geld City In canaequenca
• of the granting of this permit. SIGNATURE OF APPLICANT 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 CCPV
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERIvfIT AND INSPECTION PHASE.
I. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector 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,) 'reinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector 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 a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEONVNERS NAME: 1 itffN W I I I �
ADDRESS::':
REROOFING COMPANY NAVA: b k) CO
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPARTME`1T
•
Reroof/winword