R-5233 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 52337
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS I_ HAZARDOUS FIRE AREA
G,vw�) ��I .(-f�,V� - I` YES ❑ If yes—I understand that a Class A
NAME V "'x'YJ�� """"' �w \ met assembly is required:
NO ❑ Initial- LGB.O.M
ADDREss EXISTING ROOF COVERING
PHONE s L NUMBER OF EXISTING COVERINGS
CONTRAq$
TO BE REMOVED�TO BE RETAINED
NAME I '
ADDRESS .G1 „ �= V/ ,1 ft, TYPE OF ROOF COVERING
CITY&ZIP 1 �),V..C� Y� 11 W\'�W�
I ' Q/� ( � EXISTING
PHONE_ 415 - `c 1 "L `G. -� � - BUILT-UP ROOFLICENSE
❑
NUMBER jk� ASPHALT SHINGLES
LICENSED dONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License ClesE�' Lic.Number OTHER(SPECIFY) ❑
Dale n 2 Contractor r
4 ` ` O N -BUILDER DECLARATION p OPOSED
I hereby Jim that I am exempt from the Contractor's License Law for the foaming 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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors 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 yyyy
a civil penalty of not more than five hundred dollars($500).): P ' D
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles- I'
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES JU
Improves thereon,and who does such work himself or through his awn employees,provided that ❑ sU 24
such Improvements are not Intended or offered for sale.If,however,the building or improvement /�[4
Is sold within one year of completion,the owns r-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
C]1.as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, I �� f/1� �� � Building
as provided tardy ill main ain a of the Labor Code,Consent
the pednsure for
of Wore is C for whichansa this I Il(,(Ih
permit Is issued. $eISn11C
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the wor for which this permit is Issued.My Worker's
'Compp mado Insure a arriayesOf Policy num r ere: Total
Carnet\� PolicyN .2 �'' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
1 certify that In the performance of the work for which this permit Is Issued.I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be AGIBeLTed prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE APPUANT� shoul
subject I.theOWorrkere Compelnsati n proafterlvisionis of thelcate Laborr Code,you mustof Exemption, uforthwitlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalC be deemed revoked. 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 covering obe class'C"Or betle/r.
W
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
hereby
purposes. y1 }I
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OFAPPLICANT OATE
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
• SUBfECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spe.s
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and wrinea 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, and 3.
11) 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 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 COMPLY W= TIM
POLICY
t HOMEOWNERS NAME:
ADDRESS: D
REROOFING COMPANY NAME:
APPLICA`I 7S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Reroof/winword