R-5630APPLICATION FOR
REROOF PERMIT
• BUILDING ADDRESS
107-1 a ?Ka r Lapp
OWNER'S
NAME Mr, �`��I� •• r '
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NAME Y -A -X -w III • kJLI lil
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PHONE �IS ��+�'•+� I �'
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CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
I hereby affirm that 1 am licensed under provisions 01 Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. A
License Class c • Uc. Number 31, q 0
Data 4q Contractor &�i 111l III
OWNER -BUILDER DECLARATION LUQ
I hereby affirm that I am exempt tram 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, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
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
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 (8500).):
❑ 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 Proles.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
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 -builder will have the burden of proving that he did
not build or Improve for purpose of Bale.).
❑ 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
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.
I am exempt under Sec. ,8 & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance 01 the work for which this
permit is issued.
❑ 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
Compensa n Insurance carrier and Policy number are:
Carrier_ I) • Policy No. �h
755
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed if the permit Is for one hundred dollars ($100) or leas.)
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 Cell-
fornla.
Date Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
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
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(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 in consequence
TEAR OFF INSPECTION:
PLYWOOD:
INSP.
PERMIT
NU BER R- 5630
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
RESIDENTIAL X COMMERCIAL OTHER
YES ❑ If yes- I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. #
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
TYPE OF
ROOF COVERING
EXISTING
BUILT-UP ROOF.
.
ASPHALT SHINGLES
❑
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROPOSED
BUILT-UP ROOF
;-Kix
ASPHALT SHINGLES
❑
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
.)APPLICATION DATES VALUATION I WRW FEE I
1 PERMIT AUTHORIZATION 71� D 1 — I
'Joh
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
I Of coverings to I class "C" or better.
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SIGNATURE OF APPLICA DATE
IN -PROGRESS:
INSP. DATE
FINAL:
DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
E
CITY OF C UPERTL lO
BUILDING DIVISION 403-777-3223
RE -ROOF TEAR OFF POLICY
I. You must schedule an inspection for the tear off the day before the daze you wish the inspection to be
made. The procedure is to call the Building Division (777-3223) between the hours of 12:30 and 4:00
P.m. for ncn day inspection.
2. When the roof is torn off, the nails removed or driven in and all of the dry roved wood has been
replaced, TIEI,i YOU btUST CALL THE = BUILDING DIVISION. An inspector will be
notifd that the roof is ready, and he will respond to do the inspection as soon as his schedule will
allow. There are sp=.al hours for this service between 3:00 a.m. and 11:00 am., and between 1:00
and 3:00 p.m.
IF YOU CALL FOR THE TEAR -OFF INSPECTION AND TIM JOB IS NOT READY, THERE WILL
• BE A RE -INSPECTION FEE OF 569.00 CHARGED, WHICH MUST BE PAID BEFORE
A..NIOTrIER INSPECITON IS MADE
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• SUSIECT: REROOFDG POLICY FOR THE CITY OF CUPERTIPIO BUILDM DEPPRi"MENT
PRIOR TO ISSUA,`+CE OF PER,NIIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and mnnufacmrers sec's
on reroofing.
2. Ne•.v roof coverings shall not be aoolied without first obtaining all inspection and tea approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspth
ector when e re:cofing 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,) P:einspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke dee-:or verification
• b.) Spark arrestor installation
5. 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 sheathing and a building inspector will insect all sheathing at that time.
C�
WE UNDERSTAND TEE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TRE
POLICY
HOMEOWNERS NAME
ADDRESS:
REROOF tai 1G COMPANY NAME:
APPLICA.`TS SIGNATURE:
CITY OF CUPERTIP i0
BUILDING DEPARTtiIENT
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