R-5621 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 6 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
180 WITHIN FROM LAST CALLED INSPECTION.
MINI BUILDING ADDRESS
q q Ld
RESIDENTIAL--4—COMMERCIAL OTHER
OWNER'S '^� / 1 HAZARDOUS FIRE AREA
NAME byini9t0 IF�I'Y t_y-,N �ES--� roof assembly
is required
eq Nada Criss
root assembly h required.
NO ❑ Initial I.C.B.O.k
ADDRESSZL�� Ql LL-r1� �—� EXISTING RODE COVERING
PHONE ILi — ( NUMBER OF EXISTING COVERINGS j
CONTRACTOR'S
�
NAME S CO f11'il TO BE REMOVED TO BE RETAINED
ADDRESSC' L/ n /� TYPE OF ROOF COVERING
r• CITY&ZIP 111 J al L:T t, TTVI'/ nor f
"I EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER L q ASPHALT SHINGLES —�
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed 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.
_ � WOOD SHINGLES El Claes Lic.Number 1
Date x5-��� contractor (-`� A-�'OS — OTHER(SPECIFY) ❑
OWNER-BUILDER DECIARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason. j
(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 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 for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500),): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will da ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
cions 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 for sale.It,however,the building or improvement
IssoId within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm untler penalty of perjury one of the following declaration:
sV{y O ^
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, l! q Buildint,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which his (V\ Liii
permit is Issued. x,� m
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of H SBISRIIC
_the Labor Code,for the performance of he work for which this permit is issued.My Worker's
j Compensation urs ce ca vier and Policy number are C11 ��� Total
Carrier Policy No.4/171 MI`fyifAUTHORIZATION DA
CEIRTIFicidrE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(Thio section need not be completed it he permit i/on area Goll lis(8100 or less.)
certlly that in iha performance of the work for whit Is is shell of employany person In any manner so es to become subject t co pe canon we of cau- All roofs s e inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date,�,/ 9 7 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after makln is Certilicah of Exeh on,yolt should become A Ilcant understa nd w II comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,yo must rhwith comply pP P Y
with such provisions or this permit shall deemed revoked. source regulat
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 c e gs t 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 he City of Cupertino against liabilities, r.2
'
judgments,
granting of his permit.
which may In any way accrue against said City In consequence
ftSIG T RE OF APPLrQANT 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
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUIL.DNG DEPART:IENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must a.—Cc to comply with U.B.C. standards and manufacturers sec's
on reroofing.
2. New roof coveangs shall not be applied without first obtaining all inserion and wr sea approval
from the building inspector. A final inspection and approval shall be obtained from the building
instiector when the reroofing is comoleted.
• 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,) P:einsection or tear off aoprovul.
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 down to the sheathing and a building inspector will insect all sheathing at that time.
1VE UNDERSTAND TF" ABOVE POLICY ON REROOFING AND WILL COMPLY WITH T-HE
POLICY _
HOMEOWNERS NAMIE:
ADDRESS"`
Z L-N
Jul
REROOFING COMPANY NAME:
APPLICA`TS SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPART'
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