R 5815 PT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5815
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
RESIDENTIALyOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
S YES E] It yes—1 understand that a Class A
NAME roof assembly is required.
/�' NO r-L.
Initial i.C.B.O.#
ADDRESS /�!/n"/�� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
s A TO BE REMOVED--------f—TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP EXISTING -
PHONE - �J Q l/�/1 BUILT-UP ROOF ❑
LICENSE
NUMBER �J �i ASPHALT SHINGLES El
LIC NSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3of o Business and Professions Code,and my license Is In full force and
effect. c„-t r� WOOD SHINGLES ❑
License Class / LIC.Number 5
Date jrContractor
OTHER(SPECIFY) ❑
—OWNER OE RATION PROPOSED .
I hereby affirm I al I am exempt from the Contractors License Law fo a following reason. {
(Sac.7031.5,Business end Pro/oeaiona Code: Any city or county wN requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions I�
of the Contractor's License Law(Chapter S(commencing with Section 7000)of Division 3 aof the
lleged
ASPHALT SHINGLES
Business and Professions Catla)or that he Is exempt therefrom and the beats for the elle ao
exemption.Any fviolationtmore
of Section 7031.5 by any applicant far a permit subjects the applicant to
e civil pastry a not more than five bundredy employees
del yees (h wag): WOOD SHAKES �p L1IXA 5 EAST
❑I,as ander of the tuneproperty,not
to employees with wages as their Bole compensation,will s. l/Yry1`i
the work,and the structure Is not Inse dedLaw ores not
for sale n owner
Business and builds
o-
sions Cotle:The Contractors License Law does not apply to an owner of property who bulltls or WOOD SHINGLES . '
improve thereon,and who does such work red foil or ,If,how his awn employees,provided that C�'('Y OF y V:`L'-11111Yv
such Improvements are not plebe ,oro fferedforedea. itl however,thebuildingpros Improvement V
n sold tbuild hinor
provne e r of for purpose
sthe owner-builder will have the hurtled al proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7004,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 contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,0 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT F
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUI
as provided for by Section 3700 of the Labra Code,for the performance of the work far which This ^'
permit Is Issuetl. [)' Y//�.- if S� C
❑I have will alntel Workers Compensation Insurance,as required 6y Section 3700 of ✓ Q "elf
the Labor e,to he p ormar, he work for which this permit Is Issued.My Workers
Compeneetlonls enc errlere Policy num rare: l Total
Carrier Policy No.
� PERMIT AUTHORIZATION DAT
CERTIFICATEOF EMPINSUFROM WORD RS'
COMPENSATION INSURANCE N.0[]
(This section need not be completed it the permit is for one hundred dollars($100)or loss.) i
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'Companeetlon Laws of Cali- All roofs Shall in pected 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.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A lice erstands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P y p
with such provisions or this permit ahalGbe tlaemetl revoked. SOUrC egUlatIODS.
I certify that l have read this appllcatlon and state that the above Information is correct.I agree j
to Comply with all city and County ordinances and state Ides relating to building construction,and All r Of'covering t0 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
epe)purposes.
(Wr ^�<
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabllitlae,
judgments,Costs and expenses which may In any way accrue against said City In consequence
of 110 nngng of this permit, SIGNATUREO 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
CITY OF CUPERTINO - BUILDING DEPARTMENT
RE-ROOFING POLICY
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections and written
approval from the building inspector. A final inspection and approval shall be obtained
from the building inspector when the re-roofing is completed.
3. All types of roofs shall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1,2, and 3.
I. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
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 sheating and a building inspector will inspect all sheating at
that time.
IMPORTANT:
1. Flat roofs must have a ''/C" per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE POLICY.
HOMEOWNER'S NAME: / S
ADDRESS: (� 6
RE-ROOFING COMPNAY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
. BUILDING DEPARTMENT
Re•roo0winword