R-5689 ERMI
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5689
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 B DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
Zlftcj RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 n YES 0 If yes-I understand that a Class A
NAME 1��- G �� roof assembly is required.
NO Initial I.C.B.O,N
ADDRESS ZIM 5 1'��n 1)Ye-�_1T'q Dz> EXISTING ROOF COVERING
PHONE ZS 3 — o Ll[7 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
NAME 96AAI�IpM CF 70 BE REMOVED -X �'rO BE RETAINED
ADDRESS �, TYPE OF ROOF COVERING
CITY&ZIP L21-L LIN COL IJ AVS _ EXISTING
-PHONE 4-4- D —0(,,l BUILT-UP ROOF El
(NUMBER.LICENSE ��>b ASPHALT SHIN�GLE SD El
LICENSED CONTRACTORS DECLARATION NN /
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Q�
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect. WOO �l q
D {�I OftC El
License Class CI-3el LIC.Number C
`•
IIv , ,
Dale '"� �' Contractor +Als'frt+'rJG� 40F1J OTHER(3PECJ,%11NU ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to XN
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
I,as owner of the property,or my employees with wages as their sola Compensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profee-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or allered 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) IAfil%
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 Contractors 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 o contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
i I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUI Iden
permit is
forty Beckon 3700 of the Labor Code,for the pedormanceof the work for which this � ' ��
permit is e anissued. / Selsmi
l 7/1015-5
t' 1 have and will maintain Worker's Compensation Insurance,as required by d.My Worker's'of 7 s
th�or Coda,for the pedormance of the work for which this permit Is Issued.My Worker's Tota
Compensation Insurance carrier and Policy number ere:
Carrier '� 6OW& 04)P licy No. 2-�S '4 ' PERMIT AUTHORIZATION DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(Thos section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that in the pedormance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become suble to the Workers'Compensation Laws of Cell- All r0 'S all be inspected prior to ny roofin Sten ing
joints. // ` //r / instal d. If a roof is installed ithout fir obis' ing an
Date 7 _7 1 —� Applicant //// Z �7"�'Y/)� 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 comply PP P Y P
with such provisions or this permit shatrbe 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 all city and county ordinances and state laws relating to building construction,and AI roof overings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
n-
ep(Wiff purposes. •/ M �a `a/�1
(Wa)puree to save.Indemnify and keep harmless the City of Cupertino against liabilities, [ /ss-w+/•-lam 1 ` /�
judgments,costs and expanses 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 TIKE CITf OF CuPEcTIN0 BUILDDiG DEP-ARTMIEVT'
PRIOR TO ISSUANCE OF PERNGT A+Ni .D INSPECTION _LkSE.
I. Prior to pe mit issuance, you muss, a,ee to compiv with U.B.C. standards and macanufccers sec's
on reroofing.
2. New roof coverings shall not be aociied without first obtaining all inspection and wrinea approval
from the building in_zector. A filial ine tion and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types or roof shall be ins-pected prior to any roof being installed.
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 ir"-e tion approval.
3.) Final ir=e--ion approval.
a.) Operable smoke detector ve uiGtion
• b.) Spark arrestor installation
5. If plywood is installed,a plywood 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 she thing and a building inspr:or w— M.n fir_.all sheathing at that time.
NVE UNDERSTA,NID Tr.= ABOVE POLICY ON REROOFING PND WILL CO��LY =H T^
POLICY
' EOMEOWI-ERS NAVE:
2Q�
ADDRESS:`
REROOFING COMPANY NAME.
APPLIC. N17S SIGNATURE:
CIT!OF CUPERTINO
BUILDING DEPART'(ENT
•
Rerooftwinwdrd