R-5515 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5515 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORKS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
L Q RESIDENTIl�COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
If yes—1 understand that las
NAME—W V f assembly is required.
NO ❑ Intli I.C.B.O.p
ADDRESS
EXISTING ROOF P2VERING
G- G
PHONE Q 0 NUMBER OF EXISTING;ZINGS
CONTRACTOR'S /J
NAME LoS GA•T�S /(QOF'/ TO BE REMOVED TO BE RETAINED
ADDRESSDTYPE OF ROOF COVERING
CITY a ZIP r2'O. 949A- 1,2;21. LOS�{o'S C9 9SaS' EXI TIN
PHONE ✓S — / 7 33 BUILT-UP ROOF ❑
LICENSE
NUMBER $r,?�tf-` ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES GY°1�11
7000)of Division 3 of the Business and Professions Code,and my license is in full force and /
effect. �s WOOD SHINGLES
License Class / Lie.Number�9.; i 44 — ❑ /k�
Date Contractor— (SPECIFY) /L
OWNER-BUILDER DECLARATION DS L
I hereby afrm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,aliasimprove,demolish,or repair any structure,prior to its issuance,also requires the ILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(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 ❑
exemption.Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD 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(Sea 7044,Business and Proles-
.tons Code: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 far sale.It,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)
I 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 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR. INSTALLATION SPECS.
r ❑1 am exempt under Sec. .B 8 P.C.for this reason
Owner Date R LIt ION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I' ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensatio 7 U! I
as provided for by Section 3700 of the Labor Code,for performance of the work for whlc this / /pr�r�,.•°�
permit is Issued. " -mss/(/ / �� Sel IC
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3706 bl O/7 '•Uf,� /
the Labor Code,for the performance of the work for which this permit is issued.My Worker's H r Total
Compensation Insurance carrier and Policy number are: / 'YV
Carrier �iI�'L e�'+� Policy No. y�/�73�r PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.al]
(This section need not be completed i1 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
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fonts. installed. If a roof is-installed without first obtaining an
Date 9"7-57 Applicantly!`�*�(' inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Ex ion,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply y P
with such provisions or this permit shelgbe 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. �+� '—s. 7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, 7-5 a
judgments,casts and expenses which may to any way accrue against said City to consequence SIGNATURE OF PL T 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 INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
_OFFICE COPY
•
SUBJECT: REROOFu1G POLICY FOR THE
CITY OF CUPERTRJO ELR.DDIG DEPART`�IENT
PRIOR TO ISSUANCE OF PER 2,,Q T AND INSPECT ION
1. Poor to permit issuance, you mus agree to comply with U.B.C. standards and ry nufar, ea sec's
an re-caring.
2. New roof coverings shall not be applied w thous first obtaining all inspe^ion and wrirea approval
from the building inspector. A final inspection and approval shall be cbmined from the building
insocc or when the reroofing is comple;ed.
3. All types of roof shall be inspected prior to any roof being insallei
4. In order to receive a final,you must comole;e steps 1,2, and 3.
1,) P:einspecdon or tear off approval.
2.) In progress inspection approval.
3.) Final inspevdoa approval.
a.) Operable smoke de,.—'Or verincntion
• b.) Spark arrestor installation
5. If plywood is installed a pivwccd nail inspection is required.
6. If any roof is applied without first obtaining an irupe^.ion, you will be required to remove all =v
material down to the sheathing and a building inscr_tor will in.r _eall sheathing at that time.
`VE UNDERSTADID THE ABOVE POLICY ON REROOFING AND WILL COMPLY 1VrIrI Tri
POLICY
V
t EOivfEOW ERS NAME:
ADDRESS: Ave
REROOFING CObIPANY NAME:
APPLICANCS SIGNATuRE: ^"
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
RerooUwinwdrd