R-5604 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5604
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDRESS �,jlp ;��7 \\'�
v 16-D�hc1< L� RESIDENTIAL' COMMERCIAL OTHER
OWNER'S { �I' Q HAZARDOUS FIRE AREA
NAME / 1 �^'�' YES ❑ roof assemble stand Ihat. Class A
NO ❑ Initial I.C.B.O.0
ADDRESS � d' 6o V29tic- Ig )7 'W EXISTING ROOF COVERING
PHONE NUMBER QF EXISTING COVERINGS
CONTRA R'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS �SZ z TYPE OF ROOF COVERING
CITY d ZIP EXISTING
PHONE Q BUILT-UP ROOF ❑
CENSE
NUMBER / ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby iaffirmnion that emusi licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. hal 6 WOOD SHINGLES ElU ons Class Lic.Num
Dam Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter, demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP RO Ell
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(commsncingg wlth Section]000)of Division 3 of the
' Business and Professions Code)or that he Is exempt itterefrom 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(3500).): WOOD SHAKES
E]1,as owner of the property,or my employees with wages as tW
heir sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions 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-bullder wl 11 have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of Sale.).
❑I,as owner of the pmpety,am exclusively ontmcting 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 Y
ID
with a ontmctor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALOWMlPERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby all Into under penalty of perjury one of the following declaration: u t I �
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, //�� VAI f� BUIId In v
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �1-Jr
J
permit Is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensationsation I caTIer entl Policy number are: Total
Carder < L C Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is icor one hundred dollars($100)or lass.)
I certity that In the performance of the work for which this permit Is Issued Ishell notemploy
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- I roofs shall be inspected prir to any rooting material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a Arkers' ompe altar making this of the
of ode,you
must forthwiou tbecome
h comply Applicant understands and will comply with all non point
subject to T Workers'Compensation provisions this
of me Labor Code, y
with such provisions or this permit shall be deemed revoked. source regulations. -
I certity 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 OOf COVerin sto be class"C"or better.
hereby Suthadze representatives of this city to enter upon the above-mentioned property for spectirm purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilablllties,
oltlne entl,granWSW
and
exppero tses which may In any way accrue against said Ciry m consequence - SIGNATURE OF APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFuIG POLICY FOR THE CITY OF CUPERTPO BUIIDD;G DEP-Aa—IMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PFLASE.
1. Prior to permit issuance, you must agree to comply vith U.B.C. standards and manufac:res sec's
on re:cofing.
2. Ne,.v roof coverings shall not be applied without first obtaining all inspec:ion and written acoraval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector 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
• b.) Spark arrestor installation
5. If plywecd is installed,a plywecd nail inspection is required.
6. If any roof is applied without first, obtainin,
an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will in. c:all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CONIPLY WPPH TTM
POLICY
HOMEOWNERS NAME: ���r�L/ /�7 14
ADDRESS:: O I b d
REROOF24G COMPANY NAME: �h U(38
APPLICAti7S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
MENT
•
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