R-5548•
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OFFICE COPY
PERMIT R- 5548
APPLICATION FOR CITY OF CUPERTINO NUMB
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 l t
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
I
VES ❑ If yes I understand Class A
NAME . / `e (Y' n
4
s iced.hat
of assembly is required.
Initial I.C.S.O. St
EXISTING ROOF COVERING
/
ADDRESS �� 0 3 y!/ /n Lyl Ci9l�r �d�
PHONE Q
MBER OF EXISTING COVERINGS
-
t t
CONTRACTOR'STO
//
NAME F-- /✓/Ol l% /��� /� /G/ �`
BE REMOVED TO BE RETAINED
ADDRESS � ,/ ®nom �`��1
TYPE OF ROOF COVERING
I�'
CITY 6 ZIP ���-�-t/QY/�jAl//7 '
EXISTING
,^/_
�V� 9-(O �7�
PHONE S
BUILT-UP ROOF ❑
LICENSE ,..-
NUMBER
ASPHALT SHINGLES ❑
ED CO
LICENSNTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code,
e, andentl my license Is in lull force and
effect.
WOOD SHINGLES ❑
License Class — Lic. Number
J ;
OTHER (SPECIFY) ❑
Date contractor
OWNER -the
PROPOSED
hereby affirm that em exempt fromns the Contractor's License Lew for the following reason.
Contractor'sLicense
Business and Professions Code: Any city or county which requires e permit to
(Sec. 7ct,
alt er,Improve, Issuance,
BUILT-UP ROOF ❑ ��
to file signed stireny mentrthate. Isprioricense rovisthe
applicant for pursuantelsoreprovisions
applicant for each permit to lila a signed statement that g it licensed pursuant to the pr 3 of the
of to Contractor's License Lew (Chapter a (commencing with Section 7000) of
the 301 the
Business entl o Code) or that he Is exempt therefrom and the basis for to alleged
for
ASPHALT SHINGLES ❑
violation
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars ($500).):
CI 1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Proles.
elan Code: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGLES
thereon, and who does such work himself or through his own employees, provided that
E)Improves
such Improvements are not intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the ownar-budder 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 construct
the project (Sec. 7044, Business and Professions Code: The Contractor'. 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 Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION WE
VALUATION
PE E
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
esprovitl for by Section 3700 of the Labor Code, for the performance of the work forwhich this
�w
BUIL
Is
perml Issued.
NL
Seismic
ave
have and wall maintain Workers Compensation Insurance, as required by Section 370001
Ih Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
n�+
l' /Y�
7f
-
Compeneation Inau nce carr) r entl Po%l� number are
,' /
Total
n
t p
PERMIT AU TH - TION
DATE
carrier l fgt( — Policy No.- � 1,7
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, t shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Lawn of can-
fornta.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject I. theCE OWorrkers'C mpensation provisionls ofthecate Of Labor Code, Exemption,
ou must forthwithcecome
omplyApplicant
understands and will comply with all non point
with such provisions or this permit shell be deemed revoked.
source regulations.
I certify that I have reed this application and state that the above Information Is correctI agree
to comply with ell city and county ordinances and state laws relating to building construction, and
All roof coverings to be lass" "or be r.
hereby authorize representatives of this city to enter upon the above-mentlonetl property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City in consequence
SIGNATURE O APP T 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 J.
I.
OFFICE COPY
• SUBJECT: REROOFING POLICY FOR TI-� CITY OF CUPERTINO BUI I)Z;G DEPARTNIEN i
PRIOR TO ISSUANCE OF PERMIT ANI) NSPEC ZION' F�LAS'c.
1. Paas to permit iss taut you must agree to comply with U.B.C. s•,andards and ra=uf:c:—'rers sec's
an re -coring.
2. New roof coverings shall not be applied without first obtainin, all i=ec:ion and wracn aceroval
n
From the building inspe_:or. A final inscr_-on and approval shall be obtained from Lhe building
inspector when the reroofing is completed.
3. All types or roof shallbe inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1, 2, and 3.
1,) Pre;=ection or tnr off approval.
2.) In progress inspection approval.
3.) Final insoerSon approval.
a.) Operable smoke detector verification
b.) Spark arrestor installadpn
• 5. If plywood is installed, a plvweed trail inspection is required.
6. If any roof is applied without firs: obtaining an insoecuon, you will be requir- to remove all new
mate ial down to the shnthing and a butldtne tnspe^.or will inspect all sheathing at that time.
N'c UNDERSTAi`(D Tia ABOVE POLICY ON REROOFING PND WILL COMPLY =1H Tr^-
POLICY
HOivEEOW ERS NAME:
ADDRESS;
REROOFING COMPANY NXNE:
APPLICAN-rS SIGNATURE:
CIT`! OF CUPERTINO
BUILDING DEPAR-rv(E`lT
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