R-5173 PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBERR- 5173
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
• (408)7773228 PERMIT PIKES IF WORK IS NOT STARTED
WITHIN 10080DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRE(JS��S,
OL
103 V O I Q RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �� roof assembly is required.
NO Initial I.C.B.O.M
ADDRESS Q EXISTING ROOF COVERING
PHONE p J („J NUMBER OF EXISTING COVERINGS I
CONTRACTORS
NAME S LTQ��O,S ��G� TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP P•b � ,,lig C a 3 T__ EXISTING
PHONE T3 ✓ BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect. -_3 9 �'9�3 , Q I
[Ty WOOD SHINGLES ❑ y�
License Cles Llc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.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 Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the El
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
e civil penalty of not more than Ove hundred
pl employees
dollars(h wag p WOOD SHAKES
❑I,as owner ofthe property,t i to employeeswith wages ante.7 sole compensation,wolf s-
the work,and the structure is not intended or offered for sale(See.7044,Business and Profes-
sionCotle:The,anwho d License Lawdoes not apply toanowner of property hebuildsWOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,Improvement provided that
such improvements are not completion,
or owned for safe.IL however,the enbuildingpr or Improvement
Is not ld bull or hin
year of for purpose
sthe owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the pm ect(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($)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. IO N LY
❑1 am exempt under Sac. ,B&P.C.for this reason p
owner Date
WORKER'S COMPENSATION DECLARATION APPLIC TION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: pp `A1
[-]I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, V" BuildingMOO
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O
permit is have and. (� O SBIsfT11C
❑ have and will maintain Worker's Compensation Insurance,as permit Is I su Section 3700 of —Ift p \,\ (�'I t0d
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 0 a ter'
'Comps too Ina encs carrier and Policy number era: W92/
I� � � Total
carder Policy No.W9 y/113�SS Ur PERMIT AUTHORIZATION DATE
CSIRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(This section need not be completed If the permit Is for one hundred dollars(57 00)or lees.)
I certify that In the performance of the work for which this permit Is Issued.I shall not amploy
any person in any manner so as to become subject to me Workers'compeneabon laws of can- All roof^shall be inspected prior to any roofing material 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
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shonthe deemed revoked. SOUfCe fagUlatIODS.
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 bull construction,and All root coverings "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. c
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, 7
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. SIGNATUR FAPPLIC ATE
PRE-INSPECTION: PLYWOOD: GRESS:
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
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SUBIECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEP.4RTNIE`1T
PRIOR TO ISSUANCE OF PE ZNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and wrinen approval
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, an
I,) P:einspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all ne:v
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CONIPLY WITH THE
POLICY
HO v EOWNERS NAME:
ADDRESS'
/(-' 3 go
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPART%,vMNT
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