R-5671 :1 APPLICATION FOR CITY of CUPERTINO NUMBS R- 5 6 71
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
V RESIDENTIAL `� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE s—I undeland thatAREA
^ YES ❑ Ii as a Class A
NAME Gj� root assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRES5� � �5q� �C� r' IC�-i EXISTING ROOF COVERING -
PHONE O OC -!Z NUMBER OF EXISTING COVERINGS
CONTRACT �]
'pal._ t BE REMOVED `� TO BE RETAINED
NAME �iVYt�Zl C�.W IJ7�p E]� ��/SEC`)►CS ADDRESS TYPE OF ROOF COVERING
�O
CITV&ZIP `C ( EXISTING
,PHONE � t�l finzfrdc' t d9 5;z BUILT-UP ROOF ❑
LICENSE NUMBER — t�" ASPHALT SHINGLES
ICENSED CONT /
LRACTORS DECLARATION �L
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and (>
effect. p3 WOOD SHINGLES
Li
Licennse Class Lic.Number ;
Date Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I 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,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ww Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions N
• of the Contractor's License Lew(Chapter B(commencing with Section 70001 of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLE4
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant t0
a civil penalty of not more than five hundred dollars($500).1: / p
❑I,as owner of the property,or my employees with wages as their sole wmpensatlon,will do WOOD SHAKEECjh V ^_ ❑
the work,and the structure is not Intended or offered for safe(Sec.7044,Business and Profes- L C�
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 (`t,
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 OTHER(SPECIFY) /��/❑
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 Contractor's License Lew 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 Contractors License Law, PROVIDE MPGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
F7
I have and will maintain a Certificate of Consortia sell-Insure for Worker's Compensation, Building/07611)
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit I is have
anIssued. /_Z-�+-?7 Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3]000/ ��//
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers n� ��/ G
Compen/s�etlon Insurance�arr�er a�nd�tPolicy number are:
Total LL�
Carrier �-',• �a�G(EVL Pmicy No.2ff5EWA S'9Ry PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] l V
(This section need not be completed It the permit is for one hundred dollars($100)or less.) �a l� ,� l
I certify that In the performance of the work for which this permit Is issued,1 shell not employ L
any person In any manner so as to become subject to the Workers'Compensation Lewa of cal.-. All roofs shall be inspected prior to any roofing material being
Io`n's. 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,alter making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shalfbe 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 coverings 1 be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spection purposes. bj
(We)agree to save,indemnity and keep harmless the Clry ai Cupertino against liabilities Bjs9
judgments,costa and expenses which may In any way accrue against said City In consequerae
of the granting of this Parma. SIQNATiIiR€OF AP L ANT "
' PRE-INSPECTION: PLYWOOD: -PROGRESS:
I.
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_ f
SUBJECT: REROOFING POLICY FOR TIS CITY OF CUPERTINO BUILDING DEP R 1EN-f
PRIOR TO ISSUANCE OF PERMIT AND NSPEC"ON PHASE
I. Poor to permit iss car ce, you muse a,ee to comply with U.B.C. standards and r, -Ure:s _Spec's
on reroofing.
2. Nety roof coverings shall not be'applied without first obtaining all inspection and wri¢ea approval
from the building ir=e,--,or. A final inspe tion and approval shalt be obtained from l e building
inspector when the reroofing is comoleted.
r -
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you mti«t complete steps 1,2, and 3.
1,) P:einspep ica or tear off an rov-.1.
2.) In progress [=e--tion approval.
3.) Final inspection approval.
a.) Otic-able smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inception is required.
6. If any roof is applied without firs obi
taning an inspection, you will be required to remove all new
mate ia1 down to the sheathing and a building inspector wu"I' ---t all sheathing at that time.
`vim iJNDERS TAND IlaABOVE POLICY ON REROOFNG PND WILL COMPLY W1Tr THE
POLICY
FOL'v[EONNERS NAME: �c
ADDRESS:
REROOFING COMPANY NAME: _
APPLICANTS �=
CITY OF CUPERTNO
BMLDNG DE?ARTNIENT
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