R-5323 (2) APPLICATION FOR CITY OF CUPERTINO
PERMIT R- 5323
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�V71/�/J /u�lII , j iL a/ /J�,,..� YES X Iuy assembly is required.'ired. ClassA
NAME ��/r// �rTT /� �C.N /T Y .CL"'l�7
�^ � NO ❑ Initial— I.C.B.O.p
ADDRESS ��LL �.�d EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S,/ ,,, n y
/,i//�./Lb'� v�"'^"UN TO BE REMOVED I�� TO BE RETAINED
NAME �
ADDRESS
TYPE OF ROOF COVERING
!' 0 FG G
CITY&ZIP �3GC7
EXISTING
PHONE 972-5��� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES E]
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licansetl 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.
y71 O � SHINGLES ❑
License CI as Lc.Number '
Date' ContractorZ&011ZFV j2ff& 1,I OTHER(SPECIFY) ❑
OW NER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew 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 Contractors 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 Mr the alleged
ASPHALT SHINGLES y� fff
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).): WOOD SHAKES ' 111
pl�o ❑ ��'��'wv'fs
❑l,as owner of the property,or my employees with wages as their sole compensation,will do -J 30#v
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contractor's License Law does not apply to an owner of property who bullds orv`
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHIN ❑
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)p ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construe
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C. .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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
- ❑1 am exempt under Sac. ,B 8 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: ^ p O
❑ have and will maintain a of the
Labor
Consent to sell-insure for Worker's Compensation, Building
as mit Is Issued.tl for by Section 3]00 of the Labor Code,for the performance of the work lar which this ' .max
permit ishave
an Y Seismic
have and will maithe performance
Worker's Compensation the wokfor Insurance,permit Is
by d.My
370001
the Labor Code,for the performance of the work for which this permit la Issuetl.My Worker's
,the
Insurance terrier and Policy number are: � Total �Z �r
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed It the permit Is for one hundred dollars($100)or lass.) J C7 �I �� C ^S
I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to became subject the Worker 'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date V Applicant i`�' inspection,I agree to remove all new materials for inspection.
subject NO lto theOWorrkers'Compensation proviafter sionls of theflcate of Labor Code,you must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shaltjbe 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 stale laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities.
etlg ants,costs and expenses which may In any way accrue against said City In consequence
granting of this permit. SIGNATURE OF APPLICANT DATE
• of the
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION=
OFFICE COPY
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDL`tG DEPP.R7NIENT
PRIOR TO ISSUAaNCE OF PER1YI1T AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufac:area sec's
on rercofing.
2. Ne•.v 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.
I,) Preinspectica or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.)/ Operab.lesmokedetestorveruication
• b.)-� Spark arrestor installation
5. If plywecd 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 nv.v
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTJ5,ND THE ABO`/E POLICY ON REROOFING P_ND WILL COMPLY WITIi THE
POLICY
HOMEOWNERS NAME:
YN i�fif# Lc1CKEN$/-FG/�
ADDRESS'
REROOFING COMPANY NAME:
2
APPLICM'I"S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPART�MN-f
•
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