R-5510 PERMIT
APPLICATION FOR CITY OF CUPERTINo NUMBERR_ 5 510
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-322$ PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN PERMIT ISSUANCE OR
WI DAYS
SFFR OOM M LAST
ST CALLED INSPECTION.
BUILDINGADDRESS `I 1 b /
I031y Mica VI�(? /�Qr RESIDENTIAL COMMERCIAL(,•��/�OTHER
OWNER'S /n,.,� HAZARDOUS FIRE AREA
NAME rte""' r _til Y"\�1/L� VES ❑ It yes s I understand that. Class A
reel assembly is required.
NO Initial LC.B.O.p
ADDRESS— 03I M 1l EXISTING ROOF COVERING
t
PHONE 1S- 7 — -2-208 NUMBER OF EXISTING COVERINGS +� SAY �3R•h Zs
CONTRACTOR'S /� t C/ 'T
NAME \-OK6V-� �00'C�k� TO BE REMOVED /(A201TO BE RETAINED
ADDRESS 33ZSf? ?'/'L TYPE OF ROOF COVERING
CITU&ZIP EXISTING
PHONE �? /- �4/� BUILT-UP ROOF ❑
LICENSE (,S Z ASPHALT SHINGLES ❑
LICE SE
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.
WOOD SHINGLES
License Class C- Lic.Number 2 116 2
ADAC _' Q OTHER(SPECIFY) ❑
Data Contractor
OWNER-BUILDER DECLARATION PROPOSED I
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason. Q J
(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 Contractor's 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 dollars($500).1:
❑I,as minor 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 offered for sale(Sec.7044,Business and Profen-
' Bions 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 cemplBllon,the owner-butider will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLIE` ON DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 0 , v
❑1 have and will maintain a Certificate of Consent to self-insure for Worker'sCompansetlon,//�� \ Building vl•
as provided for by Section 3700 of the Labor Code,for the performance of the work fol which tIn A ^OO
perm Is issued. !!''..`` �/y tel/ 7 Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 `1`�N -x�'`,
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Workers
`j Compensation I(ns-uJ/m�pnce carriar e{.�,_Policy number are: n AM < Total
Carrier I ~�'� Policy No.�O7`wJ/YS PEAWT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' all
COMPENSATION INSURANCE N.C.I]
(This section need not be completed if the permit is for one hundred dollars Sl 00)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 subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
f0roiB. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT TO APPLICANT: It,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 pP P Y P
with Such provisions or this permit shall be 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,and All roof Cos to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- ` iJ
spection purposes. /-�_ I/�O�Q_�L� 7-3 4_7(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-consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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: REROOFNG POLICY FOR THE CITY OF CUPERTINO BUILDNG DEPARTNIEN
PRIOR TO ISSUA`ICE OF PERMIT AND INSPECTION P1LASB.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and m=uf c-_ers sec's
on reroofing.
2. Nety roof coverings shall not be applied without first obtaining all inscecion and wrinen accroval
from the building it see tar• A final inspe_ ion and approval shall be ebtuined from the building
inspector when the reroofing is comole:ed.
3. All types of roof shall be ince•_':ed prior to any roof being installed-
4. In order to receive a final you must complete steps 1,2, and 3.
t
1,) Preinspecdon or tear off approval.
2.) In progress inspection apprpvaL
3.) Final inspection approval.
a.) Operable snake det—lor verification
• b.) Spark arestor installation
5. If plywood is installed,a plywood nail inspection is required.
r
6. If any roof is applied without first obtaining an inspecrion, you will be requied to remove all n
mdown to ew
ate ial the shcthing and a building in :o
cer wills
inspect all sheathing at that time.
%VE UNDERSTAND TI-iE ABOVE POLICY ON REROOFNG AND WILL COMPLY W= THE
POLICY yy�� tt S/
vtM
EOMEOWNERS NAME:
jo�RIq
ADDRESS:
Go,,L �o o F 12°'7
REROOFING lG COb1PANY NAME: n
APPLICA\47S SIGNATURE: —
CITY OF CUPERTNO
BUILDING DEPARTMENT
•
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