R-5114 (2) PERMIT R_ 5114
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 /�� t�
1 c/-7-LC„) ►[ �1,� RESIDENTIAL ?S COMMERCIAL OTHER
OWNER'S . l ,q HAZARDOUS FIRE AREA
NAME Q Yglo Du�rv� YES ❑ Ifyes-lunderstand Nala ClassA
roof assembly is required.
rL[� VD p re No If EXISTING(ROOF COVERING
PHONE
ADDRESS::7-l` "� D/O�t_�.V�N6�Sr�C' "'� -
PHONE Zra q ��l �— NUMBER OF EXISTING COVERINGS
CONT
RACT/OqS ; 450
NAME (+�..NAIGSA -_6- n�1r3CTOBEREMOVED P
ARETAINED
ADDRESS 7Zg7 �JO(6LN AIX �`'�• �(�-j�7J TYPE OF ROOF COVERING
CITY aZIP
L� / Icy[ EXISTING
PHONE ` ,"1 U ^®��� BUILT-UP ROOF ❑
LICENSE
NUMBER �Jr�� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am Ilcensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. 55q
¢¢ OD SHINGLES ❑
License Class G `7� Lip.Number
Date 0 _C 1� Contractor�A)A ;5ll M.Wp1j(n OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby off urn that I am exempt from the Contractors License Law for the following reason.
(Sac.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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter g(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).):
E]1, 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 Profes-
sions Code:The Contractor's License Lew does not apply to an owner of property who bullds or
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES ❑
such Improvements are not intended or offered for sale.ll,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) yy
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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATIQN SPECS.
El am exempt under Sec. ,B 6 P.C.for this reason D
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, �u� '� BUI
as provided for by Section 3700 of the Labor Code,for the performance of the work for which thisC/.Lrx,
Poll la issued. -N �♦ rtH(IN 1l //ys//''�/!/W(('//
��IJl,have and will maintain Worker's Compensation Insurance,as required by Section 3700 of (, t Vf LU ( S81S C
ih8 La for Cotle,for the performance of the work for which this p rmit Is Issued.My Worker's
Compensation Insurance cart er and.PYllcy numberr,are: ON Total
Carrier C7� c0�NYt"poliJp No. 2496_%
� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This sectlon 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 Ich Ihla p rmpJla Issu shall not employ
any person In any manner so as to become auble to ma w a com�n La�pf call- All roofs shelf be inspected prior to any roofing terial being
forms. (J installed. If a roof is installed without first obtaining an
Date —6 Applicantinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P Y with all non Point
with such provisions or this permit shall be deemed revoked. sour regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state lave relating to building construction,and Al ofc erlrlQs IOA�as"C"or better.
hereby autli representatives of this city to enter upon the above-mentioned property for In. ) C/—y/'
spection purposes. ['
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, a '�
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
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: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEP.ARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers Spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector 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.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
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
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL C01LY WITH THE
POLICY
r �tv,� n�11JCv
Ho-,vtEO�V, RS NAME: yt
ADDRESS:
REROOFING COb1PANY NAME:
AI°oeiAr�� t�z tNCs CO, f �NC
APPLICANIMS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
• RerooBwinword