R 5135•
OFFICE COPY
R- 513 5
7
APPLICATION FOR CITY CUPERTINO NUMBER
EC DIVISION
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES WORK ISNOT
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
OSUANCEOR
190 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
{�
/01 e1" Fill ill.
/ l IIIri
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
A HAZARDOUS FIRE AREA
e Ali's S
VES It yes— I understand that a ClassA
El
NAME n
rwf assal is required.
NO Initial I.C.S.O. k
EXISTING ROOF COVERING
San Dielpf(A
ADDRESS
/I �/�fjU�ne'e„yes
PHONE C.� 7 .5- 2O — 2,0S-7
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
NAME � �
�lew IfJe /I OGl o,;e j/
//'' A �/ /
r914 ASL-, �,0
.
CITY &EZ P 1 ll` /`
O� .%a/r er Pr,,2 %EXISTING
- Ja61-.3s03
PHONE
BUILT-UP ROOF ❑
CENSE
y�
NUMBER -r�7r
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 force and
effect.
C. 3?[[
r�
WOOD SHINGLES ❑
License Class Lic. Number V
%(o e A O 4
Data Contractor
OTHER (SPECIFY) ❑
PROPOSED
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec. 7031.5, Business and Profession$ 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
o1 the Contractors 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 do liars ($500).):
C] 1, as owner of the property, or my employees with wage$ as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not intended or allerod for sale (Sec. 7044, Business and Profes.
sions Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES Cl
such improvements are not Intended or offered for sale. It, however, the building or Improvement
is sold within one year of completion, the owner -builder will have the burden of proving that he die
OTHER (SPECIFY) OO�
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 Contrealoh 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 contractors) licensed pursuant to the Contractors License Law.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
li
f67
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
BUIIdin i
permit is Issued.
SEP
I have and will maintain Workers Compensation Insurance, as required by Edition 3700 of
199EE]
Seismic
.the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
CompareaIf In ursy ecarrier and Policy umber are:
-(11 !q -Leu,
(w`1.,
w
Total
Carrier =X 4:17 Policy �P,'2 D 3 Vo
LI,1b,.,
-
No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.El
(This section need not be completed It the permit is for one hundred dollar. ($1007 or leas.)
'l1l
I certify that in the performance of the work for which this permit Is issued, I shall not employ
All roof shall be inspected prior to any roofing material being
any person In anr so as to become subject o the Workers' Compensation Laws of Cali.
fornia. /
installed. If a roof is installed without first obtaining an
Data t/ r Applic t �++
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, after al thlsertiucauff Exemption, you should become
subject to the Workers'Compensation provisions of the Labor Cotle, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shal9be deemed revoked.
source regulations.
I certify that I have read this application and stale that the above Information Is correct.) agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof van t0 be class "C” or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
x
(We) agree to save, mean lly and keep harmless the City of Cupertino against liabilities,
ICU
judgments, costa and expenses which may in any way accrue against said City In consequence
otmegranting ofthis permit.
SIGNATUREQFAPPLICANT 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
9
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SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUIL DING DEPART,` FENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must a, ee to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
ect on and aporaval shall be obtained from the building
from the building inspector. A final insp
insmector 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
bJ Spark arrestor installation
5. If plywood is installed, a plywood nail 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 TIS ABOVE POLICY ON REROOFING 'AND WILL CObIPLY WITH T"
POLICY
HOMEOWi+cRS NAME:
ADDRESS;'
REROOFING COMPANY NAMH:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPARTNIE` T
Rercof/winward
Zvi✓.JPS
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