R-5651 APPLICATION FOR CITY OF CUPERTINO NUMB PERMIT 5651
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS //
70RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
GEoQr�F nn YES [3 It yes-IunderstandthataClassA
NAME roof assembly Is required.
n, NO I� Initial M I.C.B.O.e
ADDRESS -770(, OAK MrADOCAJ C.-1- EXISTING ROOF COVERING
PHONE O - / — Z NUMBER OF EXISTING COVE/FQhS/
CONTRACTORS f �A..
NAME J GY r /•1 L/JTEIJ CAV4JT EIV �,,,(r�D�JM7 TO BE REMOVED______//��TO BE RETAINED
ADDRESSq ,�k1�7 TYPE OF ROOF COVERING
(;ITYBZIP //`,r tpi li OK
EXISTING
PHONE yob -2_59 - 7450 BUILT-UP ROOF ❑
LICENSE
NUMBER 6 �1/ i l 'C ASPHALT SHINGLES , ❑
LICENSED CONTRACTORS DECLARATION \
hereby iaffirmnion that em licensed antler provisions of Chapter g(commencing with Section WOOD SHAKES !/
]000)of Division 3 of the Business entl Professions Code,and my license is In lull force and /
effect.
/.ems 3 / 7 WOOD SHINGLES
License Class �•-�-J 1 Llc.Number `+7Q Z /�� ❑ �l
Date & ?_0`q-7 Contractor -7EF� EN OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Cade: 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 a(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).):
01,as owner 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(Sac.7044,Business and Proles-.
cions 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 completion,the owner-buiider 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 M
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO. k./1
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 units(Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICAT 014 0AIE 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 sett-insure for Worker's Compensation, - YOV O B W ldln
�
••es provided for by Section 3700 of the Labor Code,for the performance of the work for which this V�
permit Is Issued. Seismic
Z I have and will maintain Workers 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 V GUrt Hf (.
- CITY Ur Compensation Insurance end Policy number are: Total
Carrier n7' �lNQ PolicyNo.� PERMITAUTHO IZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p I� _
(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 subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofi g mate ial being
fornia, installed. If a roof is installed without first obtaining an
Date Applicant 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 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 shelCbe deemed revoked. Source regulations.
I certify that I have read this application and state 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 coverin Is to be cl sl better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
( e)
(We)agree s save,penesIndemnify and keep harmless the City ai Cupertino Ci against liabilities,
ence
• of the gran casts and expenses which may In any way accrue against said CIIY In consequence
of the granting of this permit qTq NAIril E PPLICANT 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 THM CIT-f OF CLYERTPO fiUII..DLvG DE?�RTNIENT
PRIOR TO ISSUANCE OF PER+ IIT AND NSPECION P� SE.
1. Poor to pe nit issuance, you must a;ee to comply With U.B.C. standards and manufac;rea sec's
an rercofing.
2. Nv..v roof coverings sbnll not be applied without first obtaining all in section and wrinen aceroval
from the building insoecor. A final inspection and approval shall be obtained from [he building
i=cc:or when the re:eofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you mutt complete stets 1,2, and 3.
1,) Preinspection or te^_r off apprav-.1.
2.) In progess in--�ecson approval.
3.) Final inspection approval.
a.) Operable smoke de,.--.or verification
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inspea ion is required.
6. If any roof is applied without firs obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building to fir_tar will in=r all sheathing at that time.
E UNDERSTAND T-H ABOVE POLICY ON REROOF NG AND WILL COtiCPLY WITH THE
POLICY
EOMEOWNcRSNAME: f"f0
ADDI�ss:: . 7706 OAK
REROOF u iG CON[pANY\I JANIE:
APPLICA,` I S SIGNATURE:
CITY OF CUPERTNO
BUILDING DEPARTtiENT
Reroof/wimvord