R-5529 (2) INSPECTION DIVISION PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5529
PERMIT EXPIRATION
REROOFPERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS /� ` , �r
1p PAL ye/ebi RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME N40 YES ❑ It yes—lmbly is endthat ured. DlaSSA
Mf assembly is required:
1 � �✓� NO � InitialLC.B.O.#
ADDRESS / 1,31., P�L tos 1/tiri �E s EXISTING ROOF COVERING
PHONE 1, O J , ,,� / O NUMBER OF EXISTING COVERINGS i
CONTRACTOR'S TO BE REMOVED ` S TO BE RETAINED
.N NAME C • T. Rs GIJO.y
ADDRESS d y/ (� TYPE OF ROOF COVERING
CITY a zip-/DD )6`�Al1�RSoIV O ! /
5,111 Y V1f L G ye Ir r.. EXISTING
PHONE cY��l 9� 9 $/ BUILT-UP ROOF ❑
LICENSE
NUMBER L ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license Is In full lone and
effect.
/� WOOD SHINGLES
License Clara JJ T `•� � Llc.Number � v Q 17/4r
Clete Contractor `C•T. RcGGEN OTHER(SPECIFY) /❑❑❑'��� , ,. (/ —
• OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law for the following reason. p
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to l
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 Contraclors License Law(Chapter 9(commencing with Sectlon 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 lora permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
slons 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.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 LC.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.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner oats APPLIC I • VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: wA
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensatlon, AugO r `L" Building
as provitletl for by Section 3700 of the Labor Code,for the performance of the work for which this �i/i/
cr
permit is issued v OO $eISR11C I
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of CI]f pf (�('�t Hil U
.the Leber Code,for the performance of the work for which this permit Is issued.My Workers
Compensation In-}su�rance terrier end PJo�licy number are: d ^ q� Total
Carri-:5 fu�D Policy No. it �o f d—" PERMIT UTHORIZ N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completetl if 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 roof::shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non Clint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalGbe 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 r of coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mention id property for In-
spection
n- „
sp e) purposes.
(W
(We)spree to save,indemnity and keep harmless the City of Cupertino against Ilablllilea, `
ofhe granting of this ts,costs and expenses which may In any way accrue against said City in consequence SIGNATURE PLICANT 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
SUBTECT: REROOFING POLICY FOR TEE CITf OF CUPEcTINO EL�.DDIG DEPARTMENT
PRIOR TO ISSUANCE OF PERNG T AND DIS?EC i ION� c.
1. P or to permit issuance, you must a, a to compiv with U?.C. standcrds and m=nL1f:.r._ e:s sec's
an reroofing.
2. New roof coverings shall not be apolied w thous first obtaining all inspe^ion and wriren aceroval
from the building inspector. A final in--.eion and acoraval shall be obtained from he building
insoe^_car when the reroofing is completed.
3. All types of roof shall be inspr_':ed prior to any roof ce in in_st le''
4. In order to receive a final,you mus complete steps 1,2, and 3.
Q P:einscec ion or tem off approvrl.
2.) In progress inspection approval.
3.) Final inspection approval
a.) Ooeaole smoke de:e^_:or verification
• b.) Spark arrestor installation
5. . If plywood is installed, a pivwocd nail inspection is required.
6. If any roof is allied without firs obtaining an inspection, You will be required to remove all new
material dawn to the sheathing and a building inspector Nvill in rem_.all sheathing at that time.
iVE UNDEI STrli�ID Tri A 30VE POLICY ON RE ZOOFiNG PND WII L COMPLY WlTr Ta^
POLICY
EONEEOWNERS NA.NE:
ADDRESS'
REROOFING COMPANY NAVE:
APPLICAN75 SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/winwdrd