R-5590 • APPLICATION FOR CITY OF CUPERTINO
NUs RR- 5590
INSPECTION DIVISION PERMIT EXPIRATION
'REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
I
W
AOL 180
100 DAYS OF PERMIT ISSUANCE OR
WDAYS FROM LAST CALLED INSPECTION.
BUILDING/
ADDRESS t ,
/T� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
V LK M^ t Q YES ❑ If yeas assembly
ise q that. Class A
NAME roof assembly is required.
/ NO Initial I.C.B.O.H
ADDRESS �l�.S / }"D /L`F s �j r EXISTING ROOF COVERING
PHONE I� t � NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
O , 1 TO BE REMOVED_ TO BE RETAINED
NAME G�•L� 11
ADDRESS PE OF ROOF COVERING
CITY a ZIP EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES L/Jl
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencin Ith tion WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in tut r e and
effect' WOOD SHINGLES
License Class Up.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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,eller,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 ssContractor'sanPoflicense Lew(Chapter 9(commencingisex ptwith Section 7000)of Division 3 of the
Business end Professions Coda)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation ofhan Section five hundred
byany applicant for a permit subjects the applicant to
e civil penalty of not more then five hundred employees
with
wage WOOD SHAKES ❑
❑I,as owner of the property,or tmy eemployeeswith wages as their sole compensation,will do
the work,and the Contractor's
is not Intended or offered for sale(Sec.7044,Busineproperty
end uilds or
cions Coda: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves en,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.If,ill however,the building or improvement
nsold t build rIone mprve for purpose
sChaowner-builtlerwill have the burden of proving that he did OTHER(SPECIFY) ❑
not 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 Convector'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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I a exempt undeLSec. .B 8 P.C.for this reason .
owner Aare -� APPLICATION DATE VALWa UATION PERMIT FEE
WORKER'S COMPE SATION DECLARATION
I herey affirm under penalty of perjury one of the following declaration: A
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, E� `£ Buildinn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this l �`
permit Is Issued. /� 1 LUY 1.�
1 have andwill maintain Worker's Compensation Insurance,as required by Section 3700 of n( UI- t UIJLu l(IYO I� Seismic
Na Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrier end Policy number are: /��/L/ r
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.C]
(This section need not be completed It the permit is 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 employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs sTiall be inspected prior to any roofing material being
fornia. 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,after making this Certificate of Exemption,you should become Applicant understands and I with all non Oln}
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP 'ply P
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that 1 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 Of Coverings tub CIBSS r et}er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. .../
spection purposes.
(We)agree to save, indemnlfy and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence IG URE F APPLIC NT DATE
off the 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
SUBJECT: REROOFING POLICY FOR T'rW CIT! 'OF CUPERt�tO EUILDNG DEP' 7,1E j
PRIOR TO ISSUANCE OF PER:, AIN-D INspE` tt ION PHASE.
1. Poor to pe. r it issaanr_, you mu<_t agree to comply with U.B.C. standards and n nuf c-_ea re_s
on reroofing.
2 New roof coverings shall not be acolied without first obtaining all inspection and wrinen aceroval
from the building inspe^_:or. A final insectlon and aceroval shall be obtained from the building
insuector when the reroofing is camoleted.
3. All types of roof shall be inspe ted prior to any roof being installed.
4. In order to receive a final,You must complete steps 1, 2, and 3.
1,) Preinsce^_aoa or tar off approval.
2.) In progress in_soecdon approval.
3.) Final ir=e-- ioa approval
a.) Oumbie smoke detector veriiicadon
• b.) Spark ar:estorirtrallation
5. . If plywood is installed,a plywood nail inspec ion is required_
6. If any roof is awlied without fits[obtaining an ince='lion, You will be required to remove all new
material down to the sheathing and a building it scet or wiil in rem_,all sheathing at that time.
UNDERSTAW �� ABO- POLICY ON REROOFING PND WILL COMPLY =11 Tri
POLICY
EO��O�VNeRS NAME:
ADDRESS.".
REROOFING COIvfPANY NAME:
APPLIC.kNti rS SIGNA-rJ?E:
CIT`!OF CUPERTNO
E UiLD NG DEPARTMENT
•
Reroof/winward