R-5694 i
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5694
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS /I) A�
(� ,6 1f9 I'd
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Lh/�T?i i1j/� VES ❑ roof understand that a
required
Class A
NAME !!�/I'/7 � ��/J C�!'/�i
/ `� NO Initial I.C.B.O.N
ADDRESS ( �� A��T_Zx_—rz / AD EXISTING ROOF COVERING
PHONE 01-57 Z_ r / (p ( N MBER OF EXISTING COVERINGS —(
:5(+kY--C
CONTRACTOR'S /� /� � f� TO BE REMOVED�TO BE RETAINED
F_
NAME � . �FLrv/--` F!
ADDRESS 7 072- TYPE OF ROOF COVERING
CITYaZIP 7�pZ LO
//�� pZl g EXISTING
. PHONE �YJ l 7 �°�—i � BUILT-UP ROOF ❑
LICENSE 1<
` Lp
NUMBER Z ONTRASPHALT SHINGLES ❑ J L`'y\//
LICENSE CACTORS DECLARATION /
hereby iaffirmnion that em Business
antler Professions
of e,and 9(commencing calif Section WOOD SHAKES �( '
]OOO)of Division 3 of the Business entl Proleselons Cotle,entl my license is In lull force and y /
effect.
�^ L YQ Z / WOOD SHINGLES ❑
License Cl s Lic.Number_{L/ t 1
Date11f—7convector�Wjb car_,rCjZ OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION 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
• of the Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the bests for the applicant
to ASPHALT SHINGLES
exemption.Any fviolationtmore
of than
Section hundred
by any applicant for a permit subjects the eppllcant to
a civil,analtys ow of not more man livemy mpl dollyeeam(h wag): WOOD SHAKES
❑I,as owner of me property,or to employees with wages as their sole compensation,sand
will s- ❑
the work,and the structure is not Intended or offered for eels(Sea owner
of property entl Profes-
sionCode:The,and
Licence Lawdoes not apply genowner ofproperty who builds or WOOD SHINGLES
Improves maroon,and who tloen such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.11,ill however,burden
en at pr or Improvement
Is notsold bull or
prove for purpose
sale.),owner-builder will neve 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.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
i.
Owner Aare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT EEE
I hereby affirm under penalty of perjury one of the following declaration: Ap
C]I have andwlll maintain a Certificate of Consent to self-insure for Workers Compensation, W I Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit I Is issued. ^ U` ; 7 ,0 /0 �QU Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker'Clf✓ � ( Total
Compensation Insurance carrier and Policy number are: F
Carrier Policy No. AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit no hundretl dollars($100)or less.)
I certify that In the performance of the work for ch th permit Is Issued.I she mploy
any person i ny Magner so as to become sub t to the orkerc�o av of c All roofs shall be inspected prior to any roofing materi I being
forma. installed. If a roof is installed without first obtaining an
Data Applicant spection,I agree to remove all new materials for inspection.
NOTICsubject toE eoWorkerss'Compelnsallon provafter isions of thetirs lcate of Laborr Code,you mustforthwith become comply Applicant derstands and will comply with all non point
with such provisions or this permit shall be doomed revoked. Source Pogillations.
I certify that 1 have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state Iowa relating to building construction,and All of erinTO C SS eCetter
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. /
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
c 00
ofthe gran costa and expenses which may in any way accrue against said City In consequence
of the of 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 BLILDNG DEPARTi LENT
PRIOR TO ISSUANCE OF PERMIT AND I`+'SPECTI0N ..'ASE.
1. Paas to pe mit iss once, vau must a,ee to comply with U.B.C. standards and n=ufacsea sec's
on reroofing.
2. Nety roof ccveangs shall not be apolied without first obtaining all in pection and «Tinen approval
from the building inspe^_:or. A final inspection and approval shall be obtained from the building
insoccror when the reroofing is completed.
t
3. All types of roof shall be inspr_:ed prior to any roof being installed.
4. In order to re^_c:ve a final,you Musst complete s eps 1,2, and 3.
r
I') Pre;r=e^_don or tear off approval.
2.) In progress in,ec:ion an rov-J.
3.) Final inspection.approval.
a.) Operable smoke detxtor ve iu=tion
. b.) Spark ar=or installation
3. , If plywood is installed, a pivwced nail inspection is required-
6. If any roof is applied without first obtaining an inspec icn, you will be required to remove all new
material down to the sh�thing and a building tnspe.or vvu inspe�_.all sheathing at tha[time.
AVE UNDEgSTe+u`ID T.= ABOVr- POLICY ON REROOF NG PND WILL CO, �rlITA Trt
POLICY
r. EOMEON ERS NAME: A 1 1, 1114
ADDRESS: `
Q JC
REROOFING COMPANY NAME:
APPLIC.MN7S SIGNATURE:
CITY OF CUPERTINO
BUILD NG D EP AR-M.EN-
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