R-5147 APPLICATION FOR CITY OF CUPERTINO PERMIT
U BER R- 5147
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-322$ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /.
iii �C �i� /''/ K/�/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME YES ❑ If yes—I understand that a Class A
roof assembly Is required.
Initial I.C.B.O.#
ADDRESS— ...7 "f L EXISTING ROOF COVERING'
PHONE
2 5"3.— 9 SJ NUMBER OF EXISTING COVERINGS /
CONTRACTQR'S / ^ ^ e
{—I/II�•�r Flo Ill� Tye `--`t(C~ TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
I clTv a zIP 7(0(o O V EXISTING
PHONE uv BUILT-UP ROOF Ae
I LICENSE
NUMBER 7 7 11� �S? ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my license is in lull force and C� J
affect. 2/l0 /S3 WOOD SHINGLES ❑ J !��
License Class Lie.Number
Data s� comma QAC - OTHER(SPECIFY) ❑
OWNER-BUILLD ECLARATIONPROPOSED A 9 ID
I hereby affirm that I am exempt from the Contractors License Law for the f llowing reason.
(Sec.7031 5,Business and Professions Code: Any city or county which requires a permit to Roll(_-p
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOMAg m 0 -rss--,{'1V¢( C`
applicant 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 SH' LN99twreHTIN
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to y
a civil penalty of not more than five hundred dollars($500).): WOOD 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 Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES CD
thereon,and"who does such work himself or through his awn employees,provided that
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 Contractors License Law 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Buillil
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this `r/
permit01 is issued. ✓ 6 OO Seismic
❑I have and will maintain Worker's Compensation Insurance,as repulsed by Section 3700of's
11 .,the Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance carrier all*P II yy numper are /0(0
. �S Total
Carrier rr'rl'I—r�r rrJt L/4 I) Policy No. ` PERMIT AUTHORIZATION ATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Coli- All roof.^.s II be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT subject to the WorkersTO s'Compensation provisionis ofatheflcate of Laborr Code,Exemption,
mustuforthwlltlbecome
h comply Applicant understands and will comply with all non point
with such previsions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above information Is correct.I agree
to comply with all city and county ordinances and state laws rotating to building construction,and All roof cover ng$to class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- `(/, '
sPectian Purposes. ,_/
IWe)agree to save,indemnify and keep harmless the City of Cupertino against Ilebllliles, (=� � _gyp !I/
judgments,costs and expenses which may In any way accrue against said City in consequence
• of the granting of this 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
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNbfiT AND INSPECTION PRASE.
1. Prior to pe mit issuance, you must agree to comoiy 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 wrinea approval
from the building inspector. A final inspection and approval shall be obtained from the building
insoector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
t 4. In order to receive a final,you must complete steps 1, 2, and 3.
1,) Pre:r=ecdon or tear off approval.
2.) In progress i=e•_' ion approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
3. If pl nvccd 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 inse=t all sheathing at that time.
NVE UNDERSTAND Tl-:EABOVE POLICY ON REROOFING P1vD WILL COMPLY WITII TnE
POLICY
EOMEMVi+cRS NAME:
ADDRESS::
4- REROOFING CONIPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPARTMENT
•
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