R-5528 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5528
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS w
16 7Y 7 v 7w RESID NTIAL—ZCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE A
,nQ .J.II ,L /�� 'I YE If yes-I understand that a Class A
NAME (�E e N re �� t ll- IA �r�f assembly Is required.
NO I;Y Initial I.C.B.O.k
ADDRESS /0-74/7
✓wf7fi y$r f I rC EXISTING ROOF COVERING
PHONE Z - DD NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S Rigor
NAME ayA'N'f ACir IA3G 70 BE REMOVED TO BE RETAINED_
ADDRESS // / TYPE OF ROOF COVERING
CITY&ZIP 170-5- C. 6Z I r A L n/ .S. T ?5'124 EXISTING
PHONE 2 e14 - N 4-5— BUILT-UP ROOF �{Cs ❑
LICENSE C,
NUMBER G 3 ASPHALT SHINGL S ❑
LICENSED CONTRACTORS DECLARATION .
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect. WOOD SHINGLES ❑
License Class C 3 Lic.Number 416 / 63
Date 7 Contractor
Jgiili OTHER(SPECIFY) E]�G Y�I— (7Lc
OWNER-BUILDER DECLARATION PROPOSED
I 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,after,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF 0`1\1Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions A
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the 7 (0.(-Q. ❑
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE `�tjY
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to (C�
a civil penalty of not more than five hundred dollars($500).):
❑ wa
I,as owner of the property,or my employees with"gas as their sola Compensation,will do WOOD SHAKI �G�\
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- V
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGL�� UC ❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.ll,however,the building 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 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;
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, yI Z l,x BDII g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 0 / `T
permit is issued. 1 `
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Cotle.for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier ITifTE fug) b Policy No. PERMIT AUTHORIZATIO - DA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(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[ '0 permit Is Issued,I shall not employ
any person In any manner so as to become subject to lh ✓orkers'Compensation wa of call. All roofs shall be insipected prior to any.roofing mater al being
fornia. installed. If a roof is installed without first obtain ing an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE Td APPLIANT: It, ft., Car
subject to the WorkarsCC mpensetlon provisi sof the Labor Code,cate.flExamyou must forthwiitthbecome comply Applicant understands and wi 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 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 r4covngs tobe clan better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. o z ./(We)agree to save,Indemnify antl keep harmless the City of Cupertino against liabilities, I rjudgments,Costs and expenses which may in any way accrue against said City in consequence PLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP.-DATE INSP. DATE INS P. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFii`IG POLICY FOR TI-a CITY OF CTLPECTit10 BLTLDLtiG DEPART`MEN'T
PRIOR"I'O ISSUA:`10E OF PE?', T A`ro NS2E'`ION .=�_c.
, you mus agree to comply :vith U.H.C. standards and marufaca::e:s sec's
1. Prior to pe mit issrance
on reroofing. ;
2. Ne:v roof coverings shall not be acolied without first obtaining all in_-ection and :vrinen acaroval
from the building inspector. A final inspe—dcri and aooroval shall be obtained from the building
incec,or when the reroofing is completed-
3.
ompleted3. All types of roof shall be inspected prior to any roof being installed.
4. In arder to receive a final,you must cpmolete steps 1,2, and 3.
1,) P;rnspec ion or tear off approval.
2.) In progress insec'lon approval.
3.) Final insperion approval.
a.) Operable smoke de,.--.or vetiucadon
• b.) Spark arrestor inr'alladon
5. . If plywood is installed,a plywood nail inspection is required.
6. If any roof is applied without firs obtaining an rope non you will be regtired to remove all ne:v
mate ial down to the sheathing and a butldmg inspector will inset all sheathing at that time.
AVE UNDERSTAND T11 ABOVE POLICY ON REROOF NG PND WILL COMPLY ',At :T Tr'
POLICY
EO'jvIEONVNERSNAME: /Ire�liF w/R$'!/s `til
i,rlD� yrsrA DR
ADDRESS n /
REROOFING COMPANY NAMH: /
AP?LICAN 1'S SIGNATURE:
CIT`!OF CUPERTNO
BUILDING DEPARTMENT
•
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