R-5624 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5 6 2 4
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
OWNER'S HAZARDOUS FIRE AREA
n m YES ❑ It yes-I understand that a Class A
t NAME L%r • L root assembly is required.
NO Initial I.C.B.O.Jr
ADDRESS
EXISTING ROOF COVERING
i ueY+IYI 161 NUMBER OF EXISTING COVERINGS2dokrn' ' IAb
PHONE
CONTRACTOR'S /� ^
Las, (rg L0.S JJQQ� (n� TO BE REMOVED TO BE RETAINED
NADDRESSAME P'/�1 .rn+� T (/_ I] 11�L TYPE OF ROOF COVERING
CITY&ZP -� • v 'L �'l r� Y� C �i,IW
EXISTING
PHONE .°�-�R -I 2 3 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER �cs ASPHALT SHINGLES
L CCONTRACTORS DECLARATION /
hereby affirm that em licensed
under provisions of Chapter 9(commencing with Section WOOD SHAKES Q
7000)of Division 3 of the Business endntl Professions Cotle,and my licenseIs In till force and
effect. C/
WOOD SHINGLES Cl
License Class Up.Number
Data 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 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
• 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
e civil penalty of not more than five hundred dollars($500).):
E]1, SHAKES 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 Profen ' I
dons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ s Ti
Improves thereon,and who does such work himself or through his own employees,provitletl that Vi
such Improvements are not Intended or offered for sale.If,however,the building or Improvement 11
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Q)L
not build or improve for purpose of sale.).
E]1 .8 owner of the property,em 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. ?7 S 2-3
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. PRQ1/IQE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason ��''
Owner DataC� A' ,TION TE 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, (i4- Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which thla /
parmjs la leeued.
\r)111heve and will maintain Worker's Compensation Insurance,as required by Section 3700 of �f�AO /a/ QQ SeISrr11C
th fin lbor Code,for the performance of the work for which this permit Is Issued.My Worker's 'I'
Co pens n Insu nce 'er antl Policy number are: / 'fin,/'.� n Total
Canter Policy No.( )ggLlL✓9� PERMIT AUTHORIZATION DATE
CERTIFICAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.[] 29,
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
rcertify 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 Can- All roofs 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.
come
subject lloETO the Workers'Compensation ProANT. It,after ivisions of the Certificate
Coode you musufoinwithcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that 1 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 coveRms to be class "O atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
specfion purposes. /
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, , ��" ��
judgments.costa and expenses which may in any way accrue against said qty in consequence' SIGNATURE OF APP1 ANT DATE
of the granting o of this permit.
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 i
SUBJECT: RE-ROOFING POLICY FOR TIE CITY OF CUPERTNO BUILDNG DE?P.R'P[EN i
PRIOR TO ISSUANCE OF PER.VIIT AND INSPECTION PI?-�SE.
1. Prior to permit issuance, you mus[ agree to comply with U.B.C. standards and mar[ufacsers sec's
on reroofing.
2. New roof coveangs shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inscec;ion 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 mu_R complete steps 1, 2, and 3.
1,) Preinspectioa 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 new
material down to the sheathing and a building inspector will inrr_:all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOF NG AND W LL CUMPLY WITH Tri
POLICY
FiOVIEOWNERS NANIE:
SfJ L��i
ADDRESS"
REROOFING 1G COMPANY NAME:
APPLICA`+TS SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPARTMENT
Rerocflwinword