R-5697 (2) APPLICATION FOR CITY OF CUPERTINO
rPE s RR- 5697
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI160 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNE HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO Inifil I.C.B.O.N
��or�9os,p +� EXISTING ROOF COVERING
ADDRESS `�"7Jr ��/' �� � �
PHONE NUMBER OF EXISTING COVERINGS ^C..30 0
' CONTRACTOR'S
//�/t ( TO BE REMOVED TO BE RETAINED
NAME L Pzx 1
ADDRESS / A TYPE OF ROOF COVERING
CITY 8 ZIP ifJ n-r EXISTING �
PHONE a — 0o BUILT-UP ROOF ❑
LICENSE
NUMBER 3 ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION [r7/
1 hereby affirm that I em 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 lull force and
effect. WOOD SHINGLES
License Class C-3 Llc.Number -
Date Contractor
�68 J OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's orLicensecoup Lew for the following reason.
(Sec.]0315, ,Improve and Profedemolish,
or rep Code: Any city or county which requires also
requires prmit to
sept nt,ortsu Improve.to file signed staair eny mentrthat e,p or to license issuance,to thetheions BUILT-UP ROOF ❑
applicant far such permit to flaw a 9lgnatl statement that g fah Sectio pursuant to the provisions
• of the ss an Professions
License Law(Chapter 9(commencing with Section 7000)of Division ale the
Business and Professions Cotle)or that5 b 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
e civil penalty of not more than floe hundred employees
dollyeesrs(h wag): WOOD SHAKES
❑I,as owner of the property,or to ded oywea with wages as their sole compensation,will s. ❑
the work,and the structure Is not Intended or offered for sale(Sot.7044,Business entl Proles
Bions 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(Sac.7044,Business and Professions Code:The Contractor's License Lew 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 contractors)licensed pursuant to the Contractor's License Lew. P�VIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date1ICATION ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation„ Building
cel
as provided for by Section 3700 of the Leber Cotle,for the performance of the work for which INS U/' �f1� g
permit is issued. - \�x�h /N QO Seismic A
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /
the Labor Code,far the e0 mance of the work for which this permit Is Issued.My Workers 0
Compensartlonl+finiffn� erd�f❑end Policy number are: fly/' 4 Total
Carrier -J\l KC Policy No. w- " / PERMIT A HORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.El
(This section need not be completed it the permit Is for one hundred dollars(5100)or lase.)
1 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'ComponsaHon Laws of Cell- All roots 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.
NOT CE subject t.the TO APPLICANT:
Compensation provisions of the Labor Code,s Certificate of Exemption,
must forthwith ou lbcomply Applicant understands and will comply with all non point
with such provisions or this permit shallIbe 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 odqkinas to be class"C"or
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, l
' of the granting of this perrmit dgments,costs and es which may in any way soros against said City in consequenee SIGNATURE OF APPLICANT 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 CUPERTINO EUILDNG DEPA.R MEN+i
PRIOR TO ISSUANCE OF PER:1IIT A+� INSPECTL ION PHASE.
I. Pr or to pe^nit issuance, you must a;ee to comply with U.B.C. standards and nanufac: res sec's
on reroofing.
2. New roof coverings shall not be aeolied without first obtaining all in-'.ection and written approval
from the building ins-pc--or-oA final in,e=:.ion and approval shall be obtained loin l e building
s
inecror when the re:eofing is comoleted.
3. All types of roof shall be irLrr_':ed prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) P-,--inspection or tar off aoorevrl.
2.) In progress in pec ion approval.
3.) Final ins ecdoa approval
a.) Coe-able smoke det ctor verification
• b.) Spark aaeaor installation
5. . If plywood is installed,a plywood mail ins_ectica 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 buildin=in�r_tor vviil inspect all sheathing at that time.
NE UNDERSTAND Tr= A90VE POLICY ON REROOFFNG P-ND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAbM:
2098!r -
ADDRESS: `
n r
REROOP u 1G COMPANY NAME. ^ ��
ApnL ICANPS SIGNATLRE:
CI T f OF CUPERTNO
BUILDING DEPART'vENT
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