R-5551 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 555
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. IN 180 DAVS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ' oZ $ P1 LST+ INQ 1
lt:-- Q P C Ma ASO l�}- RESIDENTIAL COMMERCIAL OTHER
OWNER'S H 1 A LpIL— 5�LOGH I HAZARDOUS FIRE AREA
L�I f� YES ❑ If yes—I understand that a Class A
NAME V (_L-..\ root assembly Is required.
NO Initial I.CB.O.a
ADDRESS �Q 099 A 7T �{��^�1Y 9so7 EXISTING ROOF COVERING
PHONE L'C' 3 S L{ /• � lZ NUMBER OF EXISTING COVERINGS
CONTRA OR'S
70 BE REMOVED 70 BE RETAINED
NAME
ADDRESS F ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOFLICENSE
❑ /
NUMBER ASPHALT SHINGLES 2`
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect WOOD SHINGLES El
License Clens Llc.Number
Dale Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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.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 to licensed pursuant to the provisions
of the Contractor's License Law(Chapter S(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: 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 Cade: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.It,however,the building or Improvement /'1 ton(1111
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ 11�C�Y���
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 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.
C]I wneram exempt untlac Sec. ,B 8 P.C.for this reason
19110 17
000*10 ° `WORKER'S COMPENSATION DECLARATION APPLICATI N DATE VALUATION PERMIT FEE
1 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, ,Q Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit Is lveood, (�"�� Seismic
T ❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700 of V
the Labor Coda,for the performance of the work for which this permit is Issued.My Workers ` ' 7 6(W Total
Compensation Insurance carrier and Policy number are: %1-4 'r V V C s.` L
Carrier Policy No. ERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
.O❑
COMPENSATION INSURANCE N
(This ostitis need not be completed N the permit Is for one hundred dollars($ C, or lass.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person In any manner sees to became subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any rooting material being
forala. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject Ito the Workers'CompeCIE TO APPLICANT: nsation proivisionls of thelcate of Labor Code,yolon,you u must forthwllitthbcomr le Applicant understands and will comply with all non point
with such provisions or this permit shalDbe deemed revoked. y p y 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 coverings to be cies better.
hereby authorize representatives of this city to enter upon the above-mentloned property for in.
spection purposes. .' - _�-.S
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, ja y
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE AP CANT 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: RE400FuVG POLICY FOR TrE CITE OF CUPERTINO BUILDING DEPART`�fENT
PRIOR TO ISSUANCE OF PERMIT ASID INSPECTION PHASE.
1. Pilar [a pe.nit issuance, you mus a,ee to comply with U.E.C. standards and manuf:c:,re:s sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all insye^ion and wrren approval
from the building inspector. A final in_spec,ion and aoorovai shall be obtained from the building
inspector ,vhen the reroofing is camoteted.
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,) P:einspeadon or tear off approval.
2.) In progress inspection approval.
3.) Final inspe:.ion approval.
a.) Oce:aole smoke d-,--.or verifictition
• b.) Spark arestor installation
3. . If plywood is installed,a plywood nail inspection 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 shmthing and a building inscr_tor will inspe all sheathing at that time.
AVE UNDERSIA,\rD TrE ABOVE POLICY ON REROOFING AND WILL COv�LY WITrI Tr-
POLICY
j.
HOMEOWNERS NAME:
1D ,S:3 �A �- � �/ IS TAo 9SO I �
ADDRESS:
REROOFING COMPANY NAME:
APPLICA`7S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTZ ENT
ReroofAvinwdrd