R 5075 PERMIT R_ 5075
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 lo-Moor
�'�,t.�wGYL VE RESIDENTII COMMERCIAL OTHER
OWNER'St/� oHAZARDOUS FIRE AREA
YES f^- VIN 1 I�ILN�;,� ❑ f assembly iste�'eedd.
hClassA
NAME -
NO ❑ Initial I.C.B.O.fl
ADDRESS �p✓'� �✓ o�/-I VE Me I SU C76 INEXISTING ROOF COVERING
t
PHONE (+ -5
Jm"' b(Z) NUMBER OF EXISTING COVERINGS I
CONTRACT(9,R'SS��e A__ ^ �,1 Y6
NAME ICS/3A(S,SA,3CE f`'osF lN(J C4•IIIVL• TO BE REMOVED TO BE RETAINED
I ADDRESS / (N�,OLN AVIS-- TYPE OF ROOF COVERING
CITY&ZIP L.+ {�
4+Z �¢� EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER S ASPHALTSHINGLES - ❑
LICENSED
CONTRACTORS DECLARATION
hereby iaffirmnion that em Business
under Professions
ions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business entl Profeeslana Cotle,and my license is In full force and
effect. q LlcG WOOD SHINGLES Q
License Claes � 1 .Number ✓91 _43G
Data q �r7Contractor-C&A3665Af)(A 9WINOTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 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,demollsh,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 8(commencing with Section 7000)of Division 3 of the
. Business and Professlons 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 clvll penalty of not more than five hundred do11ars($500).1: WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,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 AI,J�
Is sold within one year of completion,the owner-bulider will have the burden of proving that he did OTHER (SPECIFY) gl Lj"LM vi
uA
not bulla or improve for purpose of sale.). L20 s�
❑I,ec owner of the property, an exclusively nontradingwitheC ntraceticontractorsto construct 2
the protect(Sec.7044,Business entl Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT N0. .J
apply to c contractor(s)
property who builds arImproves thereon,and who contracts for such protects
with a contexempt unlicensedrSe pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 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 following declaration: _
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, . " q {ir �� S61SmIC
� BUlldm
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this djf/p'-II
permit is Issued.
j4 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of FA �� .
Jh Labor Code,Mr the performance of the work for which this permit is issued.My Worker's Sep 5 n \
Compensation Insurance carrier and Policy number are: , 'i r1 1p Total
Carrier �,iA1 FVNfl Policy No. �5 -96 IPERMITAUTHORIZ N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' lip
COMPENSATION INSURANCE N.C.[]
h (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 aubl t to the rkers'Compensation Laws of Cell- All roofs.shall bei spected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dated Applicant ° n'J� 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
subject tc the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y point
with such provisions or this permit shalgbe 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,end All rppf coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mantlonetl property for In- /f
epectlon purposes.
(W ,x` �-14C,e)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
ofthe granting of this permit.dgments,costs and expenses which may In any way accrue against said City In consequence gl NATURE 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
nFFIrF rnav
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing. , I
2. New roof coverings shall not be applied without first obtaining all insrection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1, 2,and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed,a plywood trail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY �� Q
HOMEOWNERS NAME: I 'I G2N Ey GT LOMFR,,)y
ADDRESS[: o,?rgo M Ube_ AOL
(24
REROOFING CONVANYNAME: AtS>A^y'6 �,,�y�1�G �`APPLICANTS
-
APPLICANTS SIGNATURE. A� "'
CITY OF CUPERTINO
BUILDING DEPARTMENT
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