R-5368t
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OFFICE COPY
PERMIT R_
5368
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 LASTCALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ If yes —1 understand that a Class A
NAME _�R /fll AIV&7y /�/
roof assembly is required.
NO Initial I.C.B.O. N
z.`
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EXISTING ROOF COVERING
ADDRESS Zasl4��/�
r
PHONE ��' iZ f
.:/
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S o /
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NAME
ADDRESS
yrr�CITY&ZIP
TYPE OF ROOF COVERING/6
EXISTING
r�V
PHONE
BUILT-UP ROOF ❑
LICENSENUMBER 7z7�
�4
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full farce and
sneer
�y�s
WOOD SHINGLES ❑
License Cleae =� Lic. Number
OTHER (SPECIFY)
f�Lf^ 0% F �ooly
Date Contractor
OWNER -BUILDER DECLARATION
PROPOSED
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hereby eHirm that am exempt fromthe License Lew for the following reason.
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Code: Any city or
(Sec. 70315, Business and e: Any city which requires e permit to
V Q
or to it
demolish, or rep
constant, alter, Improve, demolish, or repeat any structure, prior lope Issuance, also reproves the
BUILT-UP ROOF /
applicant for such perms to file a signed statement that Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 8 (commencing with Section 7000) at 3 of the
Business and Code) or that he is exempt therefrom and the basis for the
the alleged
ASPHALT SHINGLES ❑
violation at
exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to
he
e civil penalty of not more than five hundredyellers (h 1:
I,
WOOD SHAKES ❑
employees wag
❑ with wages as their sole compensation, wolf do
as owner of the property, or to ded
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
sions Cotle: The Contractors License Lew does not apply to an owner of property who bullas or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. If, however, the building or Improvement
to
is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY)
not or Improve for purpose of aelc
01,ea Owner of the property, amexclulusivelycontracting with licensed contractors construct
the project (Sec. 7044, Business and Professions Cotle: The Contractors License Lew does not
Law
PROVIDE LC. B.O. REPORT NO.
improv
apply to owner of property whobuilds orimprovesthereon, and who contracts for such projects
with nt licensed pursuant to the Contractor's License Law,
1 Sec. 8 P. C. for this
PROVIDE MFGR. INSTALLATION SPECS.
am exempt under
❑ am ,B reason
DATE VALUATION PERMIT FEE
Owner DatePLIC
WORKER'S COMPENSATION DECLARATION low
I hereby eHirm under penalty of perjury one of the following declaration:J•
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
/n�
v�
11
BuildingZ7
`,
as provided lot by Section 3700 of the Labor Code, for the performance of the work for which this
permit 19 ued.
(,GI_` Cjj-Seismic
Part5ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is issued. My Worker's
Compensation Insurance Policy
�6�
Ilk
Ce
Total
carrier and number era:
'% Lys✓''' S7/^wG�-4%
PERMITAUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars ($100) or lel
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell.
All roofs S I be inspe ted prior to any roofing material being
fornia.
installed. If a root is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new spection.
subject 1. the WorkersOT CE TO ' Compensation proviANT: It, after sions ofthtelcate of Labor Code, ode must foibwith ompl
y comply
Applicant understands and will coon point
Ebette7r
with such provisions or this permit shall be deemed revoked.
source regulations.
I certify that I have read this application antl slate that the above Information Is correct.I agree
to hallcity state laws
F�LFBQfC$)Y2 i I or
repesecountyordinancesantl
hereby teruonthelatinglo ontingconspertlyfoand
herebyauthorizeprp representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
to harmless City Cupertino
(We) agree and keep against Ilablllllae,
save, expenses way the
ai
judgments, costs dna expenses which may In any way accrue against said Ciry In consequence
of the granting otthis permit.
SIGNATURE OF APPLICANT DATE
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
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SUBJECT: REROOFING POLICY FOR TIHE CITY OF C�L'PECTINO BUILDL`1G DEPA.RTNIENT
PRIOR TO ISSUANCE OF PE?`l11 i AND LNSPECiON ._'A..".
1. Prior to permit iss mncq you mus: agrr_ to comply with U.B.C. standards and manufac: sea sec's
on re:coting.
2. New roof coverings shall not be aoolied witheut first obtaining all inspection and writ-,= approval
from the building it sor_:or. A final ins cion and aooroval shall be ebta ne- from the building
insae^_:or when the reroofing is comolet -.
3. All types of roof shall be inspe^_:ed prior to any roof being installed.
4. In order to receive a final you muR comolete steps 1, 2, and 3.
1,) P.cinspecaon or Lear off approval.
2.) In progress inspection approval.
3.) Final ince—cion. aooroval.
a.) Operable smoke detector verification
b.) spark arestor inst-illadOrl
S. If plywood is installed, a plywood nail inspection is required.
6. If any roof is applied without first obtaining an ince uon you will be require- to remove all new
material down t° the shcthia; and a building in ,e—_.ar vvu in_�G all sheathing at that time.
%v� UNDERST�VW Tr-- ABOVE POLICY ON FEF
NG PND WILL COMPLY WITH Tr'n
POLICY
HOMEOWNERS NAME:
ADDRESS: `
REROOFING COMPANY NAME:
APPLICA`'r5 SIGNATURE:
CITY OF CUPERTINO
BUILDING DE?ARTMENT
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