R 5823 APPLICATION FOR CITY OF CUPERTINo
NUMBER R- 5823
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
. ) 1
RESIDENTIAL `� COMMERCIAL OTHER
OWNER'S - 1 , ) x� HAZARDOUS FIR AREA
NAME S �Z2. l,J V r,� 1 I VES ❑ I�f assembly is required. ClassA
NO Iniffal I.C.B.O.a
ADDRESS 2wict2 L{y\ Y vie- EXISTING ROOF COVERING
PHONE — 2O NUMBER OF EXISTING COVERINGS
PS — D
CONTRACTOR'S
//�� ` .�.�
NAME 1 '\` TO BE REMOVED TO BE RETAINED
ADDRESS M t r � TYPE OF ROOF COVERING
CITY&ZIP `-1 U
�7 EXISTING
PHONE { 2 r .Ss BUILT-UP ROOF - ❑
LICENSE
NUMBER �j ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Dlvislon 3 of the Business and Professions Code,and my license Is In full force and
once.. - WOOD SHINGLES ❑
License Clea r Llc.Number ��_y�/O f^ -
s All SQAN OTHER(SPECIFY)y s Qao4i+S ❑
Date ContractorJ
OWNER-the Conn DECLARATION
cense PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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
to of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Dlvlelon 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
e civil penalty of not more than five hundred dollars($500),):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure is not Intended or offeretl for sale(Sec.7044,Business and Profes-
sions Code: The Contractors License Law does not apply to an owner of property who Wilds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intendedn,oroffered for able,IL however,the building pros Improvement (SPECIFY)
✓,�,�r/ j�Qkr
issoldbuild ln one fImprve for purpose
s the Owner-builderwill havemeburden of proving that he dict OTHER SPECIFY uY B
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct 2
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under See. ,B$P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: Y
1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, P A 1 D /1 BUlldm�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ct_=
permit Is Issued. SeISn71C
❑I have and will maintain Workers Compensation Insurance.as required by Section 3700 of �f(��$p�pp .�111h�rD
the Labor Cade,for the performance of the work for which this permit is Issued.My Workers kYN9${I 6 Total
Compens on Insu lice carrier and Policy numb r are: /,yf� ,
Carrier , Policy No,1G 7yo C u4 MIT AIJHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(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 am toy
any person In any ma liar so as to become subje to the Workers'Compen Iron Laws al Call- All roofs shall be inspe ted prior to any roofing 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 PPLICANT: If,alter makln is Car)' ate of Exemption,you orad become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of k e Labor Code,you mu orthwith comply pP P Y p
with such provisions or this permit shalfbe doomed 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 roof coverings to be class"Cor better.
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
of the granting of this permit. wnaequence
SIGNATU615 OF PPLIC T D T
PRE-INSPECTION: PLYWOOD: IN•PROG ESS:
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: RERGOFurG POLICY FOR Tr- CITY OF CUPERTMO =—LTLDD;G
PRIOR TO ISSUANCE OF PER.AIT .A+ND DiSPECTION PILOSE.
1. Prior to permit issuance. you mus, agree to comoiv nidi U.B.C. s•..:nda:ds and s<nuar. ea ec's
on re:cofinsz.
2 New roof coverings shall not be acci;ed «ithcut first obtaining all inspection and «tinea acczval
from the building inspector. A final insecdon and aooraval l sh: be cbtainea .am ^e cu::ding
insrec:or when the reroofing is camole:ed.
3. All tapes of roof shall be inscec:ed prior to any roof being installed.
4. In order to re^_eive a final,you mt_R complete secs 1, 2, and 3•
1,) Prei tspe^_iaa or tear off approval.
2.) In pro;ess in colon approval.
3.) Final in_secdon approval.
a.) Ccemble snake de: c:or ve—,Uc--on
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5. If plywood is installed,a plywood nail ins;ection is required.
6. If any roof is applied without first obtaining an insoe=.ion, you will be required to remove all new
material down to the sheathing and a building inspector vviIl in�r.:all sheathing at that time.
AVE UNDERSTAND THE P°OVE PGLICY ON REROOFING ?ND `NTLL COMPLY WIT_. Tri=
POLICY
HOivIEOWwr-P.S NAME -�'---7-
Z�L
A-DDRESS. T�
REROOFu rG CONIP.*rY NA.NIE: AM nq Ir GL
APPLICAti I•S SiGN?SLRE:
CITY OF CUPERTINO
BUILDfNG DE?ARTMENT
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