R-5508 PERMITR-
550
8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/ 0 416. 117-- RESIDENTIAL COMMERCIAL OTHER
OWNER'S ' �7 / HAZARDOUS FIRE AREA
YES
NAME �, v'-7 SSLry ❑ H yes-I understand that a Class A
roof assembly is required.
NO _ Initial I.C.B.O.N
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS
PHONE 9q(- —1716.
CONTRACTOR'S
NAME
e G 40 O L TO BE REMOVED E TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP— Oq-/(GQ"?'-✓ /L. c-of :05 9.��Z EXISTING
PHONE -�'' BUILT-UP ROOF
LICENSE
NUMBER 7
R / x-TJ q 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 farce and
affect. C g 7�9� WOOD SHINGLES
License Class Llc.Number 7�
Data --r`7 7 Contractor Q C 0 OTHER(SPECIFY) ❑
OWNER-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 ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500),):
1-]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 ❑
Improves 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 owns nbuilder.111 have the burden of proving that he dirt OTHER(SPECIFY)
not build or improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct 7�
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 contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
j E]I am exempt under Sec. ,B&P.C.for this reason
Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: PAID
I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, BUI
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ^
permit Is' ued. y /(Z Seismic
eve
and will maintain Worker's Compensation Insurance,as requlred by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Total
Compensation Insurance carrier and Policy number are: ��.s V ,y �l
Carrier 57'� �?"� Policy No.`7/ 1&6V ITj TH0RIZAT10N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(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 as to become subject to the Workers'compensation Laws of Cell. All roofs shall be inspected prior to any roofind material being
fornia. installed. If a roof is installed without first obtaining an
Date 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 comply PP P Y P
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 all city and county ordinances and state laws relating to building construction,and All rDOI:
b SS" atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities.
judgments,costs and expenses which may In any way accrue against said City In consequence SIG ATURE 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
i
SUBJECT: REROOFNG POLICY FOR THE CITE OF CLrPEcN
TO BUD
II. NG DEP:?RT`MENT
PRIOR TO ISSUANCE OF PER�II AIND I ISPECTION P.LA .E.
1. Poor [o permit issuance, you must a,r_ to comply with U.B.C. s•,andards and r„ rufaca_es roc's
on re:cofing.
2. New roof coverings shall not be acolied without first obtaining all inspeeion and wri. en approval
from the building inspecror. A anal inspection and approval shall be obtained from he building
inrec:or when the rereef[ng is ccmple:ed.
3. All types of roof shall be inspe—d prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) Preirupectioa or tar off approval.
2.) In progress in sn�ec:ion apprcvl.
3.) Final inspation approval.
a.) Operable smoke detector veriucadon
b.) Spark arrestor installation
• 5. . If plywood is installed,a plywood nail inrectipa is require,'—
d without first obtaining an inspection, you will be required to remove all new
6. If any roof is applie
material down to the sheathing and a building in-cc for wu inrr_:all sheathing at that time.
%VE UNDERSTAND Tia ABOVE POLICY ON REROOF NG PND WII.L COb1PLY WITii Tr'=
POLICY
HOMEOWNERS NANM:
938 X/5
ADDRESS:
REROOFING CObiPANYNA,VIE: ��
APPLICANPS SIGNATURE:
CIT!OF CUPERTNO
BUILDING DE?ART�IENT
• Reroof/winwbrd