R-5565 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5565
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESpS'\'��/\J
RESIDENTIAL COMMERCIAL OTHER
OWNER'S I / . /j l/1/ HAZARDOUS FIRE AREA
NAME `�1 Q`v\� �` ,ir L v` YES ❑ If yeas I assembly
is req that. Class A
/P/�C.�+S.,d 1v1VA` NO,roof assembly Is requlred;ial I.C.B.O.tl
ADDRESS `��C'IC�• J 1 _ r^ 'e dd EXISTING ROOF COVERING
PHONE q e�_ ��_ r NU BER OF EXISTING COVERINGS
CONTRACT WN�C V-\
W4T� �� TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
JTYPE OF ROOF COVERING
clrvaZm q �tR
EXISTING
PHONE D� `
BUILT-UP ROOF ❑
LICENSE
NUMBER 2� ZS 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.
2� WOOD SHINGLES ElLicense Class� Llc.Number
Dat. 19—114—`n M Contractor 43 OTHER(SPECIFY) ❑
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,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($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
Slone Code:The Contractors License Law does not apply to an owner of property who builds or WOODSHINGLE$
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 Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who oullds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE Ml INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION PPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensationy++ Itry� BUlldln
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which thly/ {IU
P;
t Is Iesuetl. f
Uf �Ur H $BIS
eve end will maintain Worker's Compensation Insurance,as required by Section 3700 o - t �'/Alo
ih Labor Code,for the performance of the work for which this permit Is issued.My Workers ,I
Compensetlo In mote rrieren licy nu erere: Total
Carrier Po� Policy No.{U � PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for whlch this permit Is Issued,I shell not employ
any person In any manner so as to become sub m wprkers•compensation Laws of Call. All roofs 9hall be inspected prior to any roofing material being
forma. II installed. If a roof is installed without first obtaining an
Date 9-I(l_R_� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this CarlificatAkof Exemption,you should become Applicant understands and Will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply pp P Y P
with such provisions or this permit sha ffbe deemed revoked. source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to bullding construction,and All oof cov rings to be class r better.
hereby authorize representatives of this city to anter upon the above-mentioned property for Im r'
hereby
purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
.1 the Brof Permit.
PRE-INSPECTION:
ION:N: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE_. INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR T-I:E CITY OF CUPERirNIO BNJILDLtiG DEPART IEN
PRIOR TO ISSUANCE OF PERMIT A+ND IINSpECT INSPECTION PKASE.
e, you mus. agree to comply pith U.B.C. standards and sp
1. P^or to pe mit issuancun ufarsea sec's
an rercofins.
2 Nev roof coveangs shall not be applied without first obtaining all itLspection and winen approval
from the building in_pec:or. A final iris-,e,-,ion and approval shall be obtained from he building
inspector when the rercofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to re_oeve a final,you mu_a complete steps 1,2, and 3.
1,) P:cl,=.—:ion or tear off apprcvrl.
2.) In progress inletticn a.cproNTI.
3.) Final i=cc_-ioa approval.
a.) Operable smoke de:er:or ve-Mcadcn
• b.) Spark arestor in_rallation
5. . If plywacd is installed,a plywood nail Inspection is required
6. If any roof is applied without firs-, obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspr_:or will inspe all sheathing at that time.
NVE UNDERSTAND Tr ABOVE POLICY ON REROOFING AND WILL COivIPLY WITFI fxEE
POLICY t 1 ` YI^
I30iv(EOWWcRSNA.�IE: A
ADDRESS-"
REROOFING COMPANY NAME: Zoo ( v10wAW'\1 OoF
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DE?ARTNIENT
•
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