R-5631 (2) `
PERMIT
APPLICATION FOR clrY OF CUPERTINO NUMBER R- 5631
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O 1 Q r O L JVI
Nr RESIDENTIAL OMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
M '!P-Ly N YES ❑ It yeas I assembly
stand that. Class A
NAME �.] �l 1 UL roof assembty is required.
NO ❑ Initial I.C.B.O.k
ADDRESS_ a 0 ���N EXISTING ROOF COVERING
�U �NJ
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING.
CITY 8 ZIP _ EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER o Z O 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, C�3� WOOD SHINGLES ❑
License Class qq.—�� Lid.Number
Data 16-17:22 Contractor a� OTHER(SPECIFY) ❑
OWNER-BUIUDER DELARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors 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 ASRMALPSWINGL'Eg 117
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty Of not more than live hundred yeesrs(h wag): WQ"�A��
❑I,as owner of the property,or to employees with wages as their sola compensation,will s- ❑
the work.and the structure Is not Intended ordoes
s not for sale n Owner
of Busineproperty
and Proes-
Improvns ath Th Contractor's essuchworkhi seOt apply to rthroughhiso own
ployertywho
rovidebuilds
or WOOD SHINGLES ❑
Improves ove en,and who does such work himself or.If.how his own employees.Improvement that
such Improvements aro not intended orow offered for sale.IL however,the building vi ImprovementIs INC
not ld bull or hin
prove for purpose
sthe ownarbulltler will have the burden of proving that he did OTHER(SP�CiFY) ❑
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 Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply t0 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.
C]I am exempt under Sec. ,a 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration: _
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, P Building 1�'57
ID 11
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this P
permit is Issued. $BISmIC �//ry
it and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 Do
_the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Carrier A21111
A2111urance carrier Polley numbBr are°Policy N0. NV)C�I / $SOI � Total � TE
fin/C �An�XEMP rI PERMIT AUTHORIZATION DATE
CERTIFICATE FEXEMPINSURANC WORKERS'
COMPENSATION INSURANCE G— (3 - 1 N.O❑ IessJ -7
(This section need not be completed If the permit is for one hundred dollars($100)Or /
1 certify that In the performance of the work for which this permit is issuetl. shell not employ
any person In any manner so as to become subject to the Wor rs compensation Laws of call. All roofs shall be inspected prior to any roofing material being
torula. installed. If a roof is installed without first obtaining an
Date l� Applican inspection,I agree to remove all new materials for inspection.
subject tithe WorkersTO s'Compefnsatl n proviel ns ofethelcate Labor`Code,Exemption,
ou mustuforthwithlbecome
comply Applicant understands and will comply with all non point
with such provisions Or this permit Shall 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. (laze /
Am (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may In any way accrue against said City Inconsequence
of the granting of this FarI A URE OF APPLICANT DATE
Fail
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 CUPERTMO BUILDD;G DE?PAT`ENT
Pt
tIOR TO ISSUANCE OF pER ,fIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and r,=Lfac:arers sec's
on rercoffng.
2. New roof coverings shall not be applied without first obtaining all in vection and written aceroval
from the building inspector. A final inspection and aporoval shall be obtained from the building
insoector 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 compiete 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 insertion 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 inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING ?SID WILL COMPLY WITH THE
POLICY
HO'LvIEOWNcRS NAME: Ll
ADDRESS"
REROOFG COMPANY NAS E: � S !N A) C
IN
APPLICA,vTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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