R-5281 (2) • PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5 2 81
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
&Q yd o / J0— J
RESIDENTIAL ccoMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n � VES ❑ Ifyeas I understand that. Class A
NAME L Lim t7� root assembly is required.
/ NO )illiInitial— LC.B.O.k
ADDRESS 7(P7_//� (��-Ln11 �-�' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONT
RKNAMEI 70TO BE RETAINED
gG R'S /� P0_CekD
/7
` T�� s ��' /vim' :�,./ TO BE REMOVED
NAME
ADDRESS r/ n n Y -}-, �, �6,��y n n D TY F F COVERING
CITY&ZIP Y C.J �C L!_/SLI Ct )[L (1
�7 �T/O EXISTING
PHONE �3Ca9- / qBUILT-UP ROOF ❑
LICENSE (}
NUMBER Q ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby Is[on that am Business
ssunder Professions
of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Buelneae entl Profeaelona Code,and my license is in full force and
effect.
WOOD SHINGLES ❑
License Qatiffs Llc.Number
OTHER(SPECIFY)
ElDate Zbecto
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the to wing reason. ww
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to w
construct,altar,Improve,demolish,or repair any structure,prior 10 its issuance,also requires the BUILT-UP ROOF E]applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(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 SHINGrEk ag —j
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to v
a civil penalty of not more than five hundred dollars($500),): Ujl- T
❑I,as owner of the property,or my employees with wages as their Bole compensation,will do WOOD SHAKES
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Prefers-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES h//�, ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended ar offered for sale.II,however,the bulltling or Improvement G
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,am exclusively contracting with licensed contractors to construct ��//�/yy
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO. :.MO
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.
❑I 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 following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provitletl for by Section 3700 o1 the Labor Code,for the performance of the work for which this Q� / I' �_ A
�Qrm�s issuetl.. U /� A'y/ $e15
_JQI have entl will maintain Worker's Compensation Insurance,as required by Section 3700 of (J /
Ne Tabor Code,for the performance of the work for which this permit Is issued.My Worker's
Compen 'o Insurance car' nd Polic umber ere: y Total'
carrier L POIic I7� / PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.G�
(This section need not be completed If the permit Is for one hundred doll 88
($100)or less.)
I certify that In the performance of the work for which this permit Is Issued 1 shall not employ siI
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All foots shall be inspected prior to any rootirrg ma ial being
fornia. installed. If a roof is installed without first obtaining an
Doe Applicant inspection,I agree to remove all new materials for inspection.
subjlecct tot a WOTICE TO orkers'Compensation proafter ivislons of thethis icate of Laborr Code,Exemption,
ou must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shelllbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
to hereby authorize
orzerepese county ordinances and ter upon
the above-mentioned
entiingconsperty for
IfOOt COVefln to be class'�Of belief'
hereby authorize representatives of This dry to enter upon the above-mentioned property for In- 11
r
sp we) purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, (/1�J
oftlhe grant costs
of tand his expenses which may In any way accrue against said City in consequence SIGNATU E OF APPLICANT DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. GATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BIJ'I DDiG DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1: Prior to permit issuance, you must agree to comply with U.B.C. standards and manufac uers spec's
on rercofing.
2. Nc,.v roof coverings shall not be applied without first obtaining all inspection and wrinen approval
tion and approval shall be obtained from the building
from the building inspector. A final inspec
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 dawn to the _t all sheathing at that time.
sheathing and a building inspector will inspr
%VE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COvIPLY WITH Tn�
POLICY
HOb1EOWNERS NAME: " 7 ��/
ADDRESS'." /LOa ��LLo7 �fJUuti
REROOFING COMPANYNANM: 0�'� �—
�ir Tdi i r.-�I)Y1�1lJD
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
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