R 5554 (2) ERMIT
APPLICATION FOR CITY OF CUPERTINO . NUMBER R 5554
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS - -
RESIDENTIAL_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
,, �-I YES ❑ If yes-I understand that a Class A
NAME �'••'/V'✓ roof assembly is required.
� . NO ❑ Initial I.C.B.O.q
ADDRESS Sam_ €XISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
,�`D TO BE REMOVED 0 TO BE RETAINEDy
NAME �r�(f � /�7l�Y .
ADDRESS TYPE OF ROOF COVERING
CITYBZIP / • ' t
z EXISTING
PHONE �8Z — X 2 3 BUILT-UP ROOF ❑
LICENSE
NUMBER 2 SI ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm 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
effect �J WOOD SHINGLES
Licennsee glass Lie.Number 3^
Da
I Contractor OTHER(SPECIFY ❑
OWNER-the Contractor's
ION PROPOSED CE+
hereby affirm in that am exempt from the a' Any city License Lew for the Mhos ng reason.
(Sec.7031.8,Business and Py 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 DEC 1
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions 199y
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 SHING ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to v.
e civil penally of not more than live hundred dollars($500).): WOOD.SHAKES
E]1.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-
.lone Code:The Contractor's License Lew 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 El
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,em exclusively contracting with licensed contractors to construct n
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 bulltls or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 7x
❑ have and will malnt37 a of the
of Consent for
to self-insure for Worker's Compensation,which
this- 1-all-71f
� /Z / �� �oO Building D
as provided Is for by Section 3]OO gl the Labor Code,for the performance of the work for which ihla / (//
perm la IeaueO.
have and will maintain Workers Compensation Insurance,as required by Section 3700 of / SBISRIIC /x3
ih Labor Code,for the performance of the work for which this permit I.Issued.My Worker's - Total CompensQQatlo�n77� lIy�s a a carrier and Policy number are:
Carriel`/r=� / GMR - Policy No.A&I ��� �+ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or less.) 3 - •7 _ /'7 Q•
I certify that In the performance of the work for which this permit is Issued,I shall not employ 7e �l
any person In any manner so as to become subject to the WorkafI'Comp baton Laws of call- All roots shall be inspected prior to any roofing material be ng
fornia. . installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject
NOTICE
a WorkersTO s'Compefnsetlon provisionis oftheao code you must foorthwith 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 I have read this application arid state 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 I ICO rin be clas "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spec9on purpose..
(Wit)agree to save,indemnify and keep hay way the City of Cupertino against liabilities,
, . of the grentinAsof this pePmitsas which may in any way accrue against said City In coneaquence SIGNATURE APPLICANT r DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: j
INSP. DATE INSP. .DATE INSP. DATE -
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFNG POLICY FOR THE CITY OF CUPERTNO BLTLDD;G DEPA —7'iIENT
PRIOR TO ISSUANCE OFPER19TANDiNSPE`-TIONP'?aS7.
1. Pilar to permit issuance, you must agrec to comply with U.B.C. s andcrds and mat[ufccc ea sec's
on reroofing.
2. Nev roof caverings shall not be aoolied without first obtaining all in_section and wrinen aceroval
from the building in_pector. A final inscec:ion and approval shall be obtained from the building
insuec:or when the reroofing is completed
3. All types of roof shall be inspe^_ted prior to any roof being installed
4. In order to rr_alve a final,you must complete steps 1,2, and 3.
1,) Prein_tiection or tar off approval.
2.) In progress inspection approval.
3.) Final i=ecion aporoval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
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
mate ia1 down to the sheathing and a building ince^_:or will in--we=all sheathing at that time.
AVE UNDERSTAND Tr ABOVE POLICY ON REROOFING P_ND WILL COb�LY WITH TIM
POLICY D n
HOiVIEOW%gF.RS NAME:
ADDRESS:
i
REROOFING CONIPANY NAME:
APPLICA�+'i S SIGNATURE:
CITY OF CUPERTNO
BUILDNG DE?ART, [ENT
•
Reroof/winwdrd