R-5403 APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIRR- 5403
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
<O 3 /T /N/A -r A m P�A cRESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME �rV ��Qx6� YES ❑ � roal as embly is and required. Class A
roof assembly uncle is required.
D
/ '/// S�rMir ! NO Initial LC.B.O.q
ADDRESS h 4 fVf`,//A 1 A � EXISTING ROOF COVERING
r
PHONE ono—,2s NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
y �j � 0��� TO BE REMOVED t TO BE RETAINED
NAME �/
ADDRESS _ TYPE OF ROOF COVERING
CITY&ZIP /��� ��'C E ' ��
y EXISTING
PHONE )/ 6)3'7;-2 BUILT-UP ROOFLICENSE
❑
NUMBER 3G ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
I hereby all that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
affect' �1 OOD SHINGLES C-1License Class ' `"� Lia Number
Date -9� S,7 Contractor C O E PECIFY) ❑
OWNER-BUILDliftECLARATi6lif PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which 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
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 SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
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 Proles-
slons Code:The Contractors 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 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 contractorpursuant s)licensed pursuano the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑ am exempt under Sec. ,B&P.C.for this reason
Owner DatqBI}I ION DATE VALUATION P
WORKER'S COMPENSATION DECLARATION ToU
I hereby affirm untler penalty of perjury one of the following declaration: k ���j�r��-�
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensatior, ti D B0119W
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. C t, Seis
❑I have and will maintain Workers Compensation Insurance,as required by Section 37d d O-
lhe Labor Code,for the performance of the work for which this permit Is Issued.My Worker's H L[/(.+c��/A, Tota
'Compensation Ins�ulrance carrier e�ndy'Policy number are: 4 Ilr
Carrier —R-t -�� {�. �0 Policy No
�S PERMIT AUTHORIZATION DATE
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 leas.)
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 sublect to lite Workers' m ensetion Laws el C All roofs,shall be"Inspected prior to y Mbling rjrfatnal being
forma. installed. If a root is installed without first obtaining an
Date� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after ma is Certillwle el xa yy n,you should become Applicant understands and will cont I with all non point
subject to the Workers'Compensation ions of the Labor Car ,you must forthwith comply PP P Y
with such provisions or this permit shat a deemed revoked. Source regulations.
I certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverin be classo atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. _
(We)agree 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 I RE PLI A DATE
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
• SUBJECT: RF_ROOFRgG POLICY FOR T111E CITY OF CUPERTI 1O BUILDING DE?P.RivENT
PRIOR TO ISSUANCE OF PERMIT ANI) NS?ECTION PHASE.
I. Prior to permit issuanc C, you mus agree to compiv With U.B.C. snadards and manufacturers sec's
on reroofing.
2. New roof coverings shall not be aeeiied without first obtaining all insec:ien and written aceroval
from the building inspector. A final im=cdon and approval sha l be obtained Prem he building
insucctor when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
l,) P.einscecdon or tear off aporovrl.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector ve ulcation
b.) Spark arrestor installation
s. 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 inspector will inspr_.all sheath ng at that time.
WE UNDERSTAND TABOVE POLICY ON REROOFING AND WILL COV�LY WITF_ TrIE
IE
POLICY
o v¢owNERs NA.��: rpU/ IN
HOMEOWNERS
.CWAL P„CiFPF
,ADDRESS:
REROOFING COMPANY NAME:
APPLICAIN SIGNATURE:
O
CITY OF CUPERTNO
BUILDING DEPART'
Remof/winivord