R 5187 PERMIT R_ 5187
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I , ' 1/�17 J
W'O 6w 'lee�cl W - / RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE
AREA
__TT YES ❑ IIyea—Iun thatClassA
NAME ` roof assembly is required.
NO Initial— I.C.B.O.It
ADDRESS 7W0 6a die&Wcbd, Wiqq I
EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS Oda
CONTRAC
I1C //lU�J` WM'r� TO BE REMOVED TO BE RETAINED
NAME �
ADDRESSTYPE OF ROOF COVERING
cTva zip wr
� efise plym 9—XLI7
l� 8d b J, ��5� EXISTING
PHONE �[ Q BUILT-UP ROOF ❑
CENSE
NUMBER - / -/�S ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 full force and
affect. WOOD SHINGLES ❑
License Claes J� Llc.Number �/
Date �0 Contractor — OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason,
IS so 7031.5,Business and Professions Coca: Any city or county which requires a permit to
construct,alter,Improve,compiler,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew SChapter a(ommencfng with Section 7000)of Ohr sion 3 of the
Business and Professions Cotle or that he Is exempt Iherefrom and the basis r the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit sublet he applicant to
e civil penalty of not more than five hundred dollars($500).l:
❑I,as owner of the property,or my employees with wages as their so In ensatlon,will do WOOD SHAKES ❑
the work,and the structure Is not Intentletl or offered for sale(Sec.7 ,B nese and Profes.
sions Cotle:The Contractors License Law does not apply to an own of propwho builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employe ,provi ad that ❑
such Improvements are not Intended or offered for safe.If,however,the building vement
Is sold within one year of completion,the owner-Wilder will he"the burden olprovl thathedld OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
[2 1.as owner of the property,em exclusively contracting with licensed cont �"torato a truct
the project(Sec.7044,Business and Professions Code:The Contractor'a
Live. Lggaaaa��y��yllIIlI do s not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves(hereon,and who contract IorpGgh projects
with a contmctogs)licensed pursuant to the Contractor's License Law. _
1 am exempt under Sec. ,B&P.C.to(t tyeson xP�fs PROVIDE MFGR.INSTALLATION SPECS.
❑
Owner Dare
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
have and S maintains Certificate of Consent toeperinsurefor of
Compensation, � Q BUildin `0,
as provided for by Section 3700 of the Labor Code,for me performance of the work for which this LV. g '!y_ 1
permit Is Issued. r y] � Seismic
[II have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1j�1
-the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's l�
f Compensation Insurance carrier and Policy number are: Total
r�
Carrier Policy No. P IT AWTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E
(This section need not be completed If the permit is for one hundred Collars($100)or lase.)
I certify that in the performance of the work for which this permit is Issued,I shell not employ
any person In any mer so as to become eubjec to the Workers'Comps n Laws of All roofs shall be inspected prior to any roofing material being
fornl°''x _ / installed. If a roof is installed without first obtaining an
Date U to Applicant inspection,inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.she,makinbecome
subject to the Workers'Compensation provisionis of theflcate Labor Code,Exemptof lu onmustufo thwlltlh comply Applicant understands and will comply with all non point
with such provisions or this permit shalf+be deemed revoked, SOUfCe 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 roof covering
to be lass better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
sp°cfion Purposes. J)/ _
(we)agree to save,Indemnity and keep hermteas the City of Cupertino o shat liabilities, 4I /
Judgments,coots and expenses which may In any way accrue against said City4n consequence
of the granting of this permit. G ATURE OF APPLICANT DA E
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
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERbfIT 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 written 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.
1,) Preitspection 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 inspect all sheathing at that time.
NVE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CObfPLY N TrIE
POLICY �,./
SA
HOMEOWNERS NAME: l I l)A)E C I , C �e l T Re �J _
' ADDRESS: ,O
REROOFING COMPANY NAME: C FOSS t
APPLICANTS SIGNATURE: fill
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
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