R-5400 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5400
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
0 I 1�S" RESIDENTIAk' COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
I /A; I 1 YES 7] If yes—I understand that a Class A
NAME f�L k i=""`)3 Ho NO roof assembly is required.
nitial I.C.B.O.a
ADDRESS
Iol jr�x EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S `
TO BE REMOVED TO BE RETAINED
NAMEI ��410a- ��Om{1 .N�,
ADDRESS its// TYPE OF ROOF COVERING
�+
CITY&ZIP g S �O- / ` ��� l
EXISTING
PHONE. JLrc,g1 � p�-—` 1 `_`-75 o n BUILT-UP ROOF
LICENSE
NUMBER L/5- Z O 1 v ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ %�
]000)of Division 3 of the Business and Professions Code,and my license is in full force and C7/y
effect. C — —6r�r WOOD SHINGLES P A 0 61
�.
License Clas • Lic.Number
Date ( Zo Contrac r OTHER(SPECIFY) 20
OWNER-BUILD - - PROPOSED CI
hereby affirm that em exempt from the Contract 'e License Le for the bllowing reason. ^'.'
(Sec.7031.5,Business and Professions Code: Any ci r county hich requires a permit to N Y
construct,alter,Improve demolish,or repair any structure,p caustics,also requires the BUILT-UP ROOF (./f LUrEkJO
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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 than live hundred dollars($500)J: WOOD SHAKES
❑I,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 Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,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) 1g
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 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 contrectogs)licensed pursuant to the Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 1
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation. BUIldin6
as provided far by Section 3]00 of the Labor Code,for the performance of the work for which this !r
permit Is issued.
,Jl�ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of lo Z G p(- T 9�d y Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Insurance carrier and Policy number are: r �/ - Total
Carrier ( ' -max-` '— w� PolicyNo. a I ��r PERMIT AUTHORIZATION DATE
CERTFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.D.0
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) U
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any me ner so as to becom ►j.b-Ir��o ra Compensan Lawa of Call- All roofs shall be inspect6d prior to any roofing ma erial being
fords. p installed. If a roof is installed without first obtaining an
Data ID `Lu ( gpplic t F inspection,I agree to remove all new materials for inspection.
NOTI ETO A LICANT: If,alter meld Is cant C of Exemption,you should become Applicant understands and will comply with all non point
Subject t0 the Workers'Compensailon provisi ns of the Lab Code,
you must forthwith Comply PP P y
with such provisions or this permit shall be of mad revokelL Source regulations. -
Icertitythatlhaveread this application and s bove Information is correct.l agree
to comply with all city and County ordinances and state laws relating to building Construction,antl A COverl S be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to Sava,indemnify and keep harmless the City of Cupertino against liabilities,
oftlha encs,grancg of alis expenpermites which may in any way accrue against said City In consequence $IG E AP ANT DTE
• PRE-INSPECTION: PLYWOOD: -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: REROOFL`�G POLICY FOR THE CITY OF CUPERTENO BUILDD;C- DEPP ,IENT
PRIORTO ISSUANCE OF PEPNQT AND D4SPECTION P LASE.
1. Prior to permit issuance, you mus; agree to comply with U.B.C. standards and r, aufacn ers scec's
on re:corins.
2. New roof cove:ines sball not be noolied without first obtaining all inszection and «Tire:: aceroval
from the building inspector. A final inspection and aooroval shall be obtained from Lt- 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 mu-n complete steps 1, 2, and 3.
1,) Preinsrection 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 plvwccd nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all ne.v
material w
al don to the sheathing and a building inspector will inspec-all sheathing at that time.
NVE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CON LY WITH T
ILHE
POLICY
HOMEOWNERS NAME:
ADDRESS'-'`
REROOFING COMPANY NAME:
APPLICAN17S SIGNATURE:
CITY OF CLPERTINO
BUILDING DEPARTNIEN 1
•
Rercof1wimv6rd