R-5361 APPLICATION FOR CITY OF CUPERTINO
NUPE BER 5 3 61
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
05 p WYJJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS �S (�(� EXISTING ROOF COVERING
PHONE —gyp"\�C-), NUMBER OF EXISTING COVERINGS
CONTRACTOR'S nr
�`�\�y, _ - TO BE REMOVED TO BE RETAINED ld
NAME JNJJ��W� �U1Cl. �Ul
ADDRESS -
(�� TYPE OF ROOF COVERING
�\ \t \
CIN 8 ZIP ��l L•—aT
EXISTING
PHONE —� BUILT--UP ROOF ❑
LICENSE ❑
NUMBER —
LICENSED CONTRACTORS DECLARATION ASPHALT SHINGLES
I hereby affirm that I am Ilcursed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
_ �4 WOOD SHINGLES ❑ h�'lq
License Class Lic.Number -1
OTHER(SPECIFY) ❑
Dale CC Contractor Q v fYY�
OWNER-BUILDER DECLARATION 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 r
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF JLIN p
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions �`VV R
of the Contractors 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 SHINGL. -y
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 f.Ur✓t�i(INU
❑I,as owner of the property,or my employees with wages as their sole compensation,will do LI
the work,and the structure Is not Intended or offered for sale(Sec.7064,Business and Profes-
sions 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.II,however,the building or improvement
is sold within one year of completion,the owneo-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,em exclusively contracting with licensed contractors to constructC s-
the project(SBc.7044,Business and Professions Code:The Contractor.License Law does not PROVIDelItTrU.-REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(.)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. l Vll A •F!
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 fallowing declaration: Q �`1`
1 ❑1 have and will maintain a Certificate of Consent to self-Insurs for Workers Compensation, �— l� YD♦ Building
r' as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1
permit is Issued. Seismic
he and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the
'rhe
for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrierand Icynumberare: '
Carrier - Policy No. �3l /S��p PERMITAUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(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 Cali. All roofs shat 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
subecct bEhe Workers'Compensatleon provisions oftheffLaborr code yolu nm,
you fothwiitth become
comply Applicant understands and will comply with all non point
with such provisions or this permit sha ff be deemed revoked. source regulations.
I certify that I have read this application and stale 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 Brings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
sPerpoaea. �I
(WeWe))agree to save,Indemnity and keep harmless nyythe City of Cupertino against liabilities, k•�
judgments,gran costs and expenses which may In any way accrue against said Ciry in consequence SIGNATURE O APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
• OFFICE COPY
• SUBJECT: REROOFING POLICY FOR THE CITY 'OF CUPEcTINO BUILDING DEPA.RTP CENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. stzmcinrds and n=ufac:;revs sec's
on re:cofing.
2. New roof coverings shall not be applied w _-m
without first obtaining all inection and wricten eceroval
I from the building insnr_:or. A final in--cection and approval shall be obtained from the building
inspe^_tor when the reroofing is comole: d
3. All types of roof shall be inspe^_:ed prior to any roof being installed.
4. In order to receive a final,you mtt_a complete steps 1,2, and 3.
1,) P:einscection or tar off approval.
2.) In progress inspe—_1on approval.
3.) Final inspe`ion approval.
a.) Operable smoke detector ve wcadon
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without first obm nin; an inspection, you will be required to remove all new
material down to the shathin;and a butidtng tn<pe^.pr wul inspe^.all shathing at that time.
WE UNDERSTAND Tr= ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY 1
HO�fEOW�RS NAME:
v t 1� t•l
ADDRESS:`
REROOFING CONEPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTNO
BUILDING DE?ART%vENT
i
Reroof/wimvdrd