R 5819 PERMIT
w APPLICATION FOR CITY of CUPERTINO NUMBER R- 5 819
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
D r/ ve RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
M/MTQ v YES ElIf yes—1 understand that a Class A
NAME roof assembly is requi-di
NO Initial I.C.B.O.N
ADDRESS Self f EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS.
� - -
CONTRA/nCC���OR'S
RQ N� 'P,h,[•� 1�-(J C�--r' {'�Ot TO BE REMOVED / TO BE RETAINED
NAME J
ADDRESS /�2q L;$'�C,G e TYPE OF ROOF COVERING
CITY&ZIP
[� EXISTING
PHONE TT 6
BUILT-UP ROOF ❑
LICENSE
NUMBER r�si 7,j
AS SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section OD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect.
C 3 1 WOOD SHINGLES 1:1License less Lic.Number P AM I
Date of 1 Y Contractor 1.J OTHER(SPECIFY)
OWNER BUILDER DECLARATION PROPOSED UARI 14 ANSD
hereby affirm that am exempt from the e: Any city License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requlrea a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOFCITy Of ❑
applicant for such permlt to file a signed statement that he to licensed pursuant to the provisions i.Ur'Ch I IIyU
of the Contractor's License Law(Chapter 0(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
a civil penalty of not more then live hundred dollars($500).):
❑I,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 Profee.
sions Code:The Contractors License Lew 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 will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec,7044,Busness and Professions Coda: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 contractor(s)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 Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT_L"
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, BUIId!n
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permlt l9 sued. Sets lC
eve and will maintain Workers Compensation Insurance,as required by Section 3700 of
,the Labor Cotle,for the performance of the work for which this permit le leeuetl.My Worker's
Compensation aurenc terrier entl Policy num er ere: '7 Total
Caroler Policy No. ��� I� PERMIT AUTHORI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
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 Cas. All roofs shall be inspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,alter 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 comply pP p y p
with such provisions or this permit shalfibe deemed revoked, source regulations.
I certify that l have read this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
(We)agree to save.indemnify and keep harmless the City of Cupertino against liabilities,
C� �,�•GYt,O 1 T"f sr
judgments,costs and expenses which may In any wey accrue against said Cly in consequence
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 COPY
CITY OF CUPERTINO - BUILDING DEPARTMENT
• RE-ROOFING POLICY
I. Prior to permit issuance, you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections and written
approval from the building inspector. A final inspection and approval shall be obtained
from the building inspector when the re-roofing is completed.
3. All types of roofs shall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1,2, and 3.
i. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
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 sheating and a building inspector will inspect all sheating at
• that time.
IMPORTANT:
1. Flat roofs must have a ''/a" per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE POLICY.
HOMEOWNER'S NAME: 44 /M Tot U
ADDRESS: 21 I (04- 4-4v1-e-4rA Dry v
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE: OAA
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
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