R-5708 14
PERMIT R_ 5708
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
• RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 YES ❑ It yes-I understand that a Class A
NAME IL roof assembly is required.
NO P Initial I.C.B.O.N
ADDRESS / EXISTING ROOF COVERING
/
PHONE 9 —/,0 y o NUMBER OF EXISTING COVERINGS
CONTRACT//O'R' i
NAME�LI TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP - 5-
�2
PHON�AO%�> ('G�-'q — �� 0 0 EXISTING
BUILT-UP ROOF
LICENSE
NUMBER -7 / 8 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION t_4�
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Dlvlslon 3 of the Business and Professions Code,and my license Is In full force and
.Hatt.
C3 qp" WOOD SHINGLES P
License Clara Lic.Number 0
,'L 10 OTHER(SPECIFY) n �I�II
Date Contractor D�' s`�1
OWNER-the Conn DEC's License
PROPOSED ``dry� i// �
hereby affirm that am exempt from Co Contractor's License Law for the following reason.
(Sec.70315,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,to file signedrepair Statny ement
that
is license issuance,also to
sthe BUILT-UP ROOF Ur[rJ1'I(/ �♦
of the Contractor's for such permit to file a signetl Statement that he Is licensetl pursuant to the provisions NV
of the ssanPo License Lew(Chapter h(commencing twithherefrom
Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt antforam antl the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty a not more than five hundred dollars with
wag.):
❑Les owner structure
i not I tMy ended employeeseeredfwages as(Sec.their Bole compensation,sand
Prlll do WOOD SHAKES ❑
the work,and h. structure is not Intended ores not
for sale(Sow owner
of Business antl wilds or
slops Coda: The,an who
License wowd himself rthroughhisoapply to an own
property es,pho rovide that 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 edea.It,ill however,the enbuildingpr or ImprovementIs CQuI2�
not ld bull or
year of for purpose
see.). er-bullderwlllhave the burtlenal proving that he did OTHER(SPECIFY) -�"� L
not build or Improve for purpose of sale.).
1,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 I.C.B.O.REPORT NOA)Ck
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 MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B&P.C.for this reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: o
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, % Buildina fn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this. 2 Q' -`
perm: alssuetl. 17,11010
Yl� 9� l�j ✓�/J $BISfIIIC
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of
the abor Code,for the performance of the work for which this permit Is issued.My Worker's -1� —
Compensation l'nysJy'ry�n/�c carrier ane Po�hicy(Jnumbar aro: p Total
Carder 25 �'^'-U`— Policy No. �.�30 -36—9� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed It the permit Is for one hundred calls ra($100)or less.)
I certify that In the performance of the work for which this permit Is Issuetl,I shall not employ
any person In any manner so as to become subject to Ape W era compen^ lion Lewa df Cali. All roots she be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale 7Y O Applicant c inspection,I agree to remove all new materials for inspection.
subecctNOTlCE to theOWorrkers'Compenseiorn Prov slopes ofehagl�barr Code,of Exemption,
mustufothwitlhbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that 1 have read this application and state that the above Information Is correct I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roofVerl to
be Cla "C"orbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
speepurposes.
(W )
(Waagree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURPOF APPLICANT 6ArE
of the granting of this permit.
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 shearing at
that time.
IMPORTANT:
1. Flat roofs must have a '/4" 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: � if"
ADDRESS:
RE-ROOFING COMPNAY NAME: Z�L
Oi
APPLICANT'S SIGNATURE: i
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roof/winword