R-5634 APPLICATION FOR CITY OF CUPERTINO
rPE s RR' 5634 .
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 -
(//Cj'/�/ 4 � RESIDENTIAL COMMERCIAL OTHER
OWNERS-/� HAZARDOUS FIRE AREA
/ I 1��m YES ❑ Ii yea-I understand that a Class A
NAME lJ Q, 1' A J n N i-) roof assembly is required.
/v /� NO F Initial I.C.B.O.a
ADDRESS 2�oAxLi .
V ' ck� 114 l AEXISTING ROOF COVERING
PHONE 0O NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAMElA S (�7cJ�Ll TO BE REMOVED TO BE RETAINED
ADDRESS
SIP I1 I WIVC L. �� TYPE OF ROOF COVERING
CITY �^-� EXISTING
PHONE �JJ b"I LICENSE BUILT-UP ROOF ❑
NUMBER ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ Y\
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect.
/Vy1 � WOOD SHINGLES ❑
License Class Lid.Number L43
01
Dale Ll Contractor
OTHER(SPECIFY) ❑
OWER-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,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 Contractor's 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 `5ya
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).):
C]1,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 El
thereon,andwho 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) ❑
not build or improve for purpose of sale.).
01,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 Contractors License Law. PROVIDE MFGR.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:
01 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building
r as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 4A 'o
I permit is Issued.and C� /I/,2 Seismic
❑I have end will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
�l Compensation Ins rence carrier and Policy number are: I. I (�' ITotal
Carrier �� - +'-ID Policy No. UJ9I lin S5 PEWIT AUTHORIZATION DATE
CE TI FICATE OF EXEMPTION FROM WORKER
COMPENSATION INSURANCE N
(This section need not be completed If the permit is f undr Ilan( 00)or Is s.)
I certify that in the performance of the work for wh' lhl p rmit' ueq all not a toy
any person In any manner so as to become subjac o the ars' mp tl In Lews o a1i- All roofs shall be inspected prior to any roll Material being
tornia. e�L installed. If a roof is installed without first obtaining an
DataApplicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making cert'icate of Exe ou Quid become A licant unders and I with all non point
subject to the Workers'Compensation provisions of the Labor Cotle,you m st lar wIN comply PP Y P
with such provisions or this permit shell be deemed revoked. SOUfCe regUatl
certify theft have reetl this application and slate that the above lnlormeti Is co roct.I agree
to comply with all city and county ordinances and state laws relating to bulldin cons ruction,antl All roof COV a SSS ' Or ettef.
hereby authorize representatives of this city to enter upon the above-mention pr party for in-
spection purposes.
(WOma/ 0 7 7
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may In any way accrue against said City in consequence I E OF PL ANT DATE
of the granting of this Permit.
PRE-INSPECTION: PLYWOOD: V 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 THE CITY OF CUPERTNO BUII DLN1G DEPART`ANT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
, you must agree to comply with U.B.C. standards and mrur
anufacrers ep's
1. Pilar to permit issuance
on rercofing.
2. Ne•.v roof coverings shall not be applied without first obtaining all ins-,e---,ion 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.
i
4. In order to receive a final,you must complete steps 1, 2, and 3.
1,) P:einscection or tear off approval.
2.) In progress inrection 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 ne•.v
inspector will inspect all sheathing at that time.
material down to the sheathing and a building
E UNDERST,6,ND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TriE
W
POLICY n
HOMEOWNERS NAME. 'I
ADDRESS:
2 L Low R Q 1T
r
REROOF24C COb1PANY NAME:
APPLICA,N SIGNATURE:
CITY OF CUPERTINO
BUILDING D
EPART-NIENT
Reroofhvimvord