R-5683 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5683
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/r _ - K V�_ yes-I understand that a CINAMEt 1 f SDrrlbly is required.
N I " I.C.B.O.#
ADDRESS I�SIa MdElal4 DR XISTING ROOF COVERING
PHONE -73(- - 98 3 3 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME— TO BE REMOVED--------Ili TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYsZIP Io3I4 LAA OndA5 w!�vl. cq_csotM
� EXISTING
PHONE yob 252- SI2G _ BUILT-UP ROOF `,❑
LICENSE , I"7 4oll ASPHALT SHINGLES ,
NUMBER T /
LICENSED CONTRACTORS DECLARATION +�
hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
f
Business and Professions cense
]000)of Division 3 0l the d PraliCotle,entl my license is in lull force end
effect.
y WOOD SHINGLES '7
License Class `� Llc.Number • x
Date 12.11r.7Contractor OTHER(SPECIFY ❑
OWNER-BUILDER DECLARATION • PROPOSED � ' D
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to -I�(j p j sfr
construct,after,improve,demolish,or repair any structure,prior to its Issuance.also requires the BUILT-UP RO F/ r/rn-9 Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions REG{/
of the Contractor's License Law(Chapter 9(commencing with Section 70001 of Division 3 0l the If'.f!
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SITYNdLE$p
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to tH11NU
a civil penalty of not more than five hundred dollars($500).):
❑ WHK
WOOD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do atim B
the work,and the structure is not Intended or offered for sale(Sec.]044,Business and Profes-
sions 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 owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
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 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 MFGR. INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 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: 1
1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, BUlldlna
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1,
permit issued. .S 1 r
1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 7 Z+' / ( J 000•^ seismic `
the Labor Code,for the performance of the work for which this pg�M•�issued.My Worker's t Total
.the
Insurance carrier and Policy number are: ` /
Carrier STM« ALAACJ Policy No.---%. PERMITAUTHORIZAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed It the permit is for one hundred dollars($100)or leas.)
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 slitaffb Pis ,
to an O m erial b ng
fornia. installed. If a roof is I out fi t obtaining an
Data 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 P Y P
with such provisions or this permit shallibe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All r Ofc Bring to be class' o better.
hereby authorize pure lEa representatives of this city to Doter upon the above-mentioned property for In- �^
herebon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City in consequence
of me 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
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDNG DEPART" (ENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECT ION PHASE.
1. Poor to pe mit issuancq you mus a;ee to comply with U.B.C. standards and m.:rtufac;rers spec's
on remofing.
2. New roof coverings sball not be 000lied without firs[ obtaining all in_7ec:ion and wrinea approval
from the building insr_:or. A final in,e=:ion and approval shall be obtained from L.�e buildins
insoe^_:or when the reroofing is camoleted
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must comolete steps 1,2, and 3.
1,) Preinspectioa or tear off approval.
2.) In progress irmection approval.
3.) Final i=e•_'doa aooroval.
a.) Operable smoke de:ec:or verutcation
• b.) Spark arrestor insalladon
5. . If plywood is installed,a plywood[tail inspection is required.
6. If any roof is applied without firs', obtaining an inspection, you will be required to remove all new
tna[e Tal down to the sheathing and a buildin=inspe for will in�e—_.all sheathing at that time.
%VE UNDE-RSTAND Tr ABOVE POLICY ON REROOFING AND WTLL CObIPLY RJITrr' THE
POLICY 1 l wt Cmal(G
,
HONIEOW ERS NANCE:
Q
( o S/ o JLIEDEQI4
ADDRESS: `. a�,
S P-al '9
REROOF'NG COMPANY NAME:
�tu[
Apor ICA` I'S SIGNATURE:
CIT`!OF CUPERTINO
BUILD NG DEPARTMENT
•
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