R-5573 (2) BERR- 5 5 7 3
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMI
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT ' (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNE If HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
'NAM /"Y roof assembly is required
ix
NO Initial I.C.B.O.#
f ADDHE .3 DiexpeYI�r. `"P xJay/ EXISTING ROOF COVERING
PHONE (000) 7?f7^ qgvLNUMBER OF EXISTING COVERINGS
i CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP EXISTING
PHONE BUILT-UP ROOFS . [:1LICENSE
NUMBER ASPHALT SHIN ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am si licensed under prostates of Chapter 9(commencing with Section WOOD SHAKES
7000)pl Division 3 0l the Business and Professions Cotle,entl my license is in lull force entl
affect.
WOOD SHINGLES
License Class LIC.Number '
OTHER(SPECIFY) ❑
Dare 7 contractor t/J`
OWNER-BUILDER DECLARATION PROPOSED
1 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 Lew(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 A
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civ penalty of not more than five hundred dollars($500).):
I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
❑
t Aork,and the structure Is not Intended or offered for sats(Sec.7044,Business and Profes-
smnsCode:The Contractor's 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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 contractogs)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
owner -_Date APp IOFYT DATE VALUATION PERMIT F
WO 'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
i ❑1 have and will
6 maintain a Certificate of Consent to salt-insure for Workers Compensation, SEP d REC-D n BUlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this `
�
permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of C) Uf' �Ur-
$el
_the Labor Code,for the performance of the work for which this permit Is issued.My Worker's tYr j)I've Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE N.C.O Y�
(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 10
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,after making this Certificate of Exemption,you should become Applicant understands an with all non point
subject tp the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp y p
with such provisions or this permit shalCbe deemed revoked. source 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 laws relating to building construction,and All roof cover' to be c iter.
hereby authorize representatives of this city to enter upon the above-mentioned property for im
spectlon purposes. / 9
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
' of tthe granting of this perrmitdments,costs and aea which may In any way accrue against said City in consequence GNIATUREOFAPPLICANT 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
• SUBIECT: REROOFuNG POLICY FOR 'FHE CITY OF CLrERTI,\ ;G DE?ARTnIE` k
PRIORTOISSUA.`ICEOFPEPYQT A-IMrSPE'''IONP�=.Sc.
1. Prior to pe.-ic ssu rr_, you mu a ea to ccmoiv n,,i h U.E.C. s.:rd::cs and manuf:c-_ers secs
on remonrg.
2 Ne.v :cc[coverings shall not be :c?lied Nvithcut :`:rst eb(:iaia_ all ;"=. ecion and wrren acercvai
from the building in-ne^_•or. A nnZi itL—p==uon and aeorov
sa( shall be cou.^.e_ lm tk
ae building
inector when the rerconng.is ccmoieted.
3. All types of roof shall be inse^_-ed prior to any roof ceing in<ralled.
4. In order to receive a final,you m•_`t complete reps 1, 2, and 3.
1,) P:ein-mccuon or tear off aucrcvul.
2.) In progress ir"—ecien apprcvzL
3.) Final n�e�_�on approval
a.) Oceracle poke detec:or ve::fiGtion
• b.) Spar's ar.estor inrnAadct'
5. . If plywood is ins'slled,a plywood nail inspection is ieauire3
6. If pay roof is appli4 without first obtaining an iasce=an, you will be regtur d to remove all new
material down to the shc.hing and a building inspe=_.or wu inti all shcthLtg at that time.
NE TJNDEFSTA,`ID I"r? PEOVE POLICY ON RH COFNC P*ID WII L Col Y Vv z: Tr'�
POLICY
HO��oNvcFS HANE:
ADDRESS: :
REROOFING CObIPANY NAbIE:
AFFLIC A"N7S SIGNATURE:
CI i!OF CUPERTNO
BUILDNG DUAR'I'A(E`T
•
Reroof%vinwdrd