R-5098 (2) PERMIT R_ 5098
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS n
;1.33 e r 1 a&C-11 RESIDENTIAL COMMERCIAL OTHER
OWNER'S //�1 HAZARDOUS FIRE AREA
/•t YES [:] I(yes—I understand that a Claw
NAME i /IIrV �.i 7 roof assembly is required.
// NO ❑ Initial I.C.B.O.tt
ADDRESS Cr��ajtr efi , EXISTING ROOF COVERING
• PHONE / ✓ / f7 / NUMBER OF EXISTING COVERINGS If f
CONTRACTOR'S �/!� TO BE REMOVED TO BE RETAINED
r NAME J_A'S
ADDRESS�� ga ��'ll �I/ �S G'�1 Q.S /// ,J TYPE F €RIN
clrvazlP /L.(p T- �%T" EXISTING
PHONE ,358--I Z 3 So r
BUILT-UP ROOF J 4
R
NUMBER 3 ASPHALT SHINGLES El `
NUMBE
LICENSED CONTRACTORS DECLARATION - /
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 1Y$'�,
7000)of Division 3 of the Business and Professions Code and my license.a in full force and
effect L/ WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PAI
El(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to PI`
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(rommencing with Section 7000)of Divlslon 3 of the .S
• Business and Professions Coo)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESAPR 1 r9
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).): SHAKES[31,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHACITY Vr k,Ut'a IINO
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
slops Code:The Contractor's License Law does not apply to an owner of property no 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.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) ❑
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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a 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:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building 13Z On
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
per sissuatl. Seismicip have end will maintain Worker's Compensation Insurance,as required by Section 3700 of Q
the abor do,for the p ormance of the work for which this permit is issued.My Worker's 0 7Q Q Total 3
Co pens n In rance rnor and Policy number are: f ' I I (' (/
Carder M IQ Policy No. lW/l /lam\' PERMIT AUTHORIZATION DATE
CERTIFICArE 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.) 7 i
.. 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 Cell. All roots&Talrbe inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data4—f&!f 7 Applicant r'-- - '� inspection,I agree to remove all new materials for inspection.
subject O 1.the Workers'CompeE TO APPLICANT: nsation proviafter slonis of thel1cate of Laborr Code,you muat Iodhwsho lltlhbecome
comply Applicant understands and will 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 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. ,I
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �� 4�/F-7 7
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE ANT 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
J
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPARTMENT
PRIOR TO ISSUArNCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
'i 2. New roof coverings shall not be applied without first obtaining all in_'ection 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,) 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 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 inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS MIKt
bfG/lowLeY
ADDRESS . 2- 1337
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTivtENT
• Reroof/winword