R-5654 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5654
.
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 LASTCALLED INSPECTION.
.
BUILDING
/ADDRESS
J /� �i
J\ � L.i RESIDENTIAL COMMEflCIAL OTHER
OWNER'S ` , HAZARDOUS FIRE AREA
- /1 { r `" r _ ( YES ❑ If yes-I understand that a Class A
NAME I, Irl-Vl, r'T7� roof assembly is required.
NO Initial I.C.B.O.a
ADDRESS I'T�`��' l ' EXISTING ROOF COVERING
PHONE S 3-(v�'[' NUMBER OF EXISTING COVERINGS /
S CONTRACTOR'S ^ r
I/1 i.C�� r7 TO BE REMOVED TO BE RETAINED
I NAME T 11 `� IT'
r ADDRESS ��� gO x 9(p3 C I P TYPE OF ROOF COVERING
CITY&ZIP - _ �f EXISTING
PHONEff��� / BUILT-UP ROOFLICENSE
)
NUMBER L-:21_2V0 1 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
/1 WOOD SHINGLES
License Class Com— Lic.Number P yy
aD_�J7 OTHER(SPECIFY)
Date
OWNER-BUILDER
BUILDS BUILDER DECLARATION PROPOSED 4
hereby affirm that I am exempt from the Contractor's or roue Lew for the uires a reason. <
(Sec]ct,alt Business and Professions Code: Any city or county which requires a permit to -
applicuct,eller,improve,demolish,sign d statement
any structure,that he prior to els Issuance,also reproves the BUILT-UP ROOF I/v`yrL-C`7,J1(I-
of the
for such(wrens m flaw a signed r 9(commencing
that g it licensed pursuant to the provisions
of the Contractor a License Lew(Chapter 9(commencing with Section 7000)of Divisionohe 3 of the
. Business and Professions Coda)or me.he Is exempt infero and the bowie for the alleged ASPHALT SHINGLES
exemption.Any violation of healon hundred
by any 8($1500).for a permit subjects the applicant to
e civil penalty or not more than live y employees
dollars 1h wag): WOOD SHAKES /�❑
01,as owner of the property,or to employeeswith wages as their Bole compensation,will s.
the work,and the structure is not Intended Low ores not for sale(Sec.7044,Business and Prolan
liens Code:The,an who
License Lawtli self apply or
ugh hiso n employers,who rovidebuilds or WOOD SHINGLES41,
Improves thereon,and who does such work ed for or through his own employees,Improvement thet
such improvements are not intended or owner-builder
for leer.ill however,the building or Improvement
Is sOid uildwithin prove for purpose at
owner-buleder will have the burden of proving that did OTHER(SPECIFY
not builtl or Improve for purpose of sale.). L.
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractors License Law does not PROVIDE LC.B.O.REPOR
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. .B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration: O
L]I he"and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. 6Seismic L (en
-11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /D(
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's l/
Compensation Insurance carrier and Policy number are: Total
Carrier policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 08 A
COMPENSATION INSURANCE N.C.O
(This section need not be completed If 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 es to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any tooting rillarterial being
fornia. installed. If.a roof is installed without first obtaining an
Dale 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 will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comps,
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 011 city and county ordinances and slate laws relating to building construction,and All r00I rings t I °or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- Q 6-23-5)
/
In-
spection agree to r x `-'_�5,
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
..c. •vim,(,(
judgments,costa and expenses which may in any way accrue against said Cly in consequence SIGNATURE 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
SUBJECT: REROOFING POLICY FOR Tri CITE OF CUPERTNO BUILDL`iG DEPARTi IENI
PRIOR TO ISSUANCE OF PEPNG T AND NSPE'=t ION PHAS'F.
1. Prior to pe mit issuance, you mus; agree to comciv with U.B.C. standards and manufacnuers sec's
on reroofing.
Z. New real coverings sha11 not be applied w theut first obtaining all inspe^_:ien and written aceroval
from the building ins,�e^_tor. A final in, on and aoprovat s:all be obtained from the building
inspector when the reroofing is comole:ed.
3. All types of roof shall be inspected prier to any roof being installed.
4. In order to receive a final,you Must complete steps 1, 2, and 3.
1,) P:cinscection or tear off aperevrl.
2.) In progress in e--don approval.
3.) Final inspection approval.
a.) Operable smoke detector verincation
• b.) Spar's arrestor installation
5. . If plywood is installed,a pivwced nail inspection is required
6. If any roof is applied without firs-, obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inrr_t all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING PND WILL COMPLY WITH. Tri
POLICY
FiOvfEOWNERS NAME:
ADDRESS:
REROOF LIG COMPANY NA!v1E:
�. w
APPLICA,+"I•vS SIGNATURE:
CIT!OF CUPERTNO
BUILDING DEPARTN(ENT
• n
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