R-5653 APPLICATION FOR CITY OFCUPERTINO
NUMB PERMIT 5 6 5 3
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
93a Ne,v Haien, G1 ck�e, r;ko
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES [:] If yes—I understand that a Class A
y�
NAME 1 r IY. w„lr'-fy � L!L(r p lA k" roof assembly is required.
01 NO Initial I.C.B.O.q
ADDRESS R 3,;)L NP t� �{Ct VPx l..f'1 EXISTING ROOF COVERING
PHONE 1108 055 — Q NUMBER OF EXISTING COVERINGS
CONTRACTORS
TO BE REMOVED_ TO BE RETAINED
NAME
r ADDRESS IN
+ CITY&ZIP EXISTING
t PHONE BUILT-UP ROOF .
LICENSE ❑
NUMBER IASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION j
hereby i affirm of em Business
under Professions
lone of Chapter 9(commencing calif Section WOOD SHAKES [� /
7000)of Division 3 0l the Buslneae entl Profeeslona Cotle,and my license le In lull lona and
effect. WOOD SHINGLES ❑ ��
License Class Lie.Number
Date Contractor 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,alta"Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he IS licensed pursuant to the provisions
of the Contractor's License Lew(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 NAM
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of no more than five hundred dollars($500).): WD HAKES
JKI,as owner of the property,or my employees with wages as their sale compensation,will do OO $ ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen
sions Code:The Contractor'°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,improvement etl that
such Improvements are not Intended or offered hi for sere.If,however,the buildingemployees,
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.
1 am exempt under Sac. ,B 8 P.C.for this reason
WORKER'S COM ENSATION DECLARATION
t APPLIC61 QfiE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, n[ n Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1{yj LIP
permit Is issued. Seismic
❑1 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's t" VUN to (\7j"Y7r Total
Compensation Insurance terrier and Policy number are: `M V
Y
Carrier Policy,No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' Ina,
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($100)100)o ;,R—)
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 Call. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO PLIANT: If.after makintssubject to the Workers'Compensation provlslons of thelcate Labor`Code,you mustufothwllthbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shelflbe deemed revoked. source regulations.
1 certify that I have read this application and state that the°hove Information Is correct)agree
to comply with all city and county ordinances and state Tawe relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In. A
apatite)purposes.
We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• ofdthe granting of this perrmit ea which may In any way accrue against Bald City in consequent° SIGNATURE OF APPLICANT A��
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BLTLDD;G DEPART?LENT
PRIOR TO ISSUANCE OF PERMIT A�ND NSpFC-1ION P!L-1SE.
1. Prior to permit issuance, you must a;ee to compiv with U.B.C. standards and manufacMre:s sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all in_,ection and wriren aceroval
s
from the building inec-mr. A final tnserton and apocoval shalt be obtained from the building
1 msec:or when the re:oonng is completed.
3. Ail types of roof shall be inspected prior to any roof being installed
4. In order to receive a final,you m'-n Complete steps 1,2, and 3.
1,) Preinse^_ion or tear off approval.
2.) In progress inspection approval.
3.) Final inserion approval.
a.) Operable smake de,.t=or verification
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inset ion is required-
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
trate *1 down to the sheathing and a building insae---or wul inseam_.all sheathing at that time.
%t� iJNDERSTAND Ila ABOVc POLICY ON R-- COFNG AND WILL CO��LY �xIITri THE
POLICY
_—
EO'L,,CEOV[NcRS NAME:
ADDRESS;
t REROOFING COMPANY NAME: ,
APPLICA MS SIGNATURE: --� �22J —
CITY OF CUPERTNO
BUILDING DUART ZMENT
•
Reroof/winwdrd