R-5333 APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIT 5333
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM_AST CALLED INSPECTION.
BUILDING ADDRESS
1030 Kg`s A05- RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1` I �I / J� understand
HAZARDOUS FIRE AREA
�/�T H 1 w' f �D-Z^& YES ❑ If yes untie is req That a Class A
NAME roof assembly is required.
//^/� p��//�l - NO �' Initial I.C.B.O.k
ADDRESS,//J 32 Q 910 "1!fS A10 e ' EXISTING ROOF COVERING
PHONE 8 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'
NAME C-11if TO BE REMOVED TO BE RETAINED
lf'ADDRESSl Y Qct �` - TYPE OF ROOF COVERING
JCZY azlP �1�A A n n I CA-
9f�j EXISTING
PHONE 4 i 2 BUILT-UP ROOF - ❑
CENSE
NUMBER LICENSEASPHALT SHINGLES ❑
D ACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license Is in full force and /
effect' X� WOOD SHINGLES
License Class LIC.Number Tc J
` OTHER(SPECIFY)
Date 1 Contractor
1 OWNER the Conn DEC's LicenON
se
PROPOSED
hereby affirm(hal am exempt from the Contractor's License Law for the following reason. L
(Sec.70315,Business and demolish,
or re Code: Any city or county which requires also a permit to
constapplicant
such Improve,permittlemelas or repairny structure,prior tolls Issuance,also quires the BUILT-UP ROOF ❑
applicant lar such permit to file a signed statement that he is licensed pursuant to the provisions
• of the ss an Pro ssi ns Lew(Chapter B(commencing with Section 7000)of for the 3 of the
Business and Professions Codi)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 70315 by any applicant for a permit subjects the applicant to
e dull penalty a not more than five hundred yellers with
wage WOOD SHAKES
❑I,as owner of the property,or to employees with wages as their sole compensation,will do ❑
the work,any the structure is not intended or offered for sale(Bac.7044,Business and Profen
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 -
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 Law does not PROVIDE LC.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 MFG`R.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APP TI N DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
7 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, will Building
as provided for by Section 3700 of the Labor Code,for the performance of the work larwhich this 1 �./�
permit is issued. p s/p $eismIC _�./- V
❑I have and will malntein 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 (/
Compensat suranca car ar and Policynumbererg:-' 1^ LOY� D� Total
arrierWAIR —-%P Policy No. PERM( AUTHORIZATION DATE
CERTIFICATI OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit Is for one hundred dollars S1 0)or less.) C_�LLL.rV
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 Cali. All roof^shall be inspected prior to any rooting material being
fornia. , installed. If a roof is installed without first obtaining an
Date ^� Applicen' inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: If,after making t rlificate of Exemption,you should become Applicant understands and w' I with all non point
subject la the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP Y P
with such provisions or this permit shalQbe 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 to be cl SS r atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon purposes. ` 077
•'')
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, /8Jf ljjj ,� / j— 07 /
• judgments,costs and expenses which may In any way accrue against said City In consequence'
of the granting of this permit, SIGNATURE OF AP LICANT 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: REROOF�`G POLICY FOR THE CITY OF CUPER 1 0 BUII_DD;G DEPAA7NIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
It,
1. Prior to permit issuance, you must a,ec to comply with U.B.C. standards and manufacturers sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all insecticn and written approval �
from the building inspector. A final inspection and approval shalt be obtained from the building
inscector when the reroofing is completed.
3. All types of roof shall be inspected prior to any rcof be; installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) P:einspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verificaticn
• 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 ince:or will insect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON RER00F11 C' P.ND WILI CO"[PLY WITH Tx•E
POLICY
HOMEOWNERS NAME: I
ADDRESS: `
REROOFING 1G COb1PANY NAME:
APPLICA,`7i'S SIGNATURE:
CITY OF CUPERTINO
BUiLDNG DEPART'NII:NT
Reroofhvimvord