R-5574 (2) APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIT 5574
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
AL 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS U j{�I �1 4o J fir
IP6 ii 1 '� LY\ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 OV\ 1 !Z A A6� VES ❑ If yesI understand that. Class A
NAME T►�1. '{ roe assembly-Iundo is required.
I NO Initial I.C.B.O.If
ADDRES� PA(;L41 q j 4 EXISTING ROOF COVERING
PHONE �VI 0 , -/� D NUMBER OF EXISTING COVERINGS I
• CONTRACTOR'S L e _ r�
NAME :JG�CAACk n
ADDRESS r�pDt—a rl� S��/C.�/�� TO BE REMOVED TO BE RETAINED
w( ril TYPE OF ROOF COVERING
CITY 8 ZIP�S77 /t)/ S kii SAO 1O7& 9, EXISTING
r
PHON O BUILT-UP ROOF ❑
SE
NUM ER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section OOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license 1s In lull force and
effect.
WOOD SHINGLES ❑
License Clea /'Sgf4-2Lic.NumeerS , L)
Date q'3-ell Contractor S;Jt AdL, � 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 q
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Lr"
apalcant for such permit to 1119 a signed statement that he Is licensed pursuant to the provlalons
of the Contractors 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 P
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /1
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES y n/rY (4
1,as owner of the property,or my employees with wages as their solo compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. Ur Lur.
sions Coda:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES C
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.).
❑1,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 LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
r Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: c .�
❑I have and will maintain a Cerelicate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. I a0 seismic \
-11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �S
the Labor Code,for the performance of the work for which this permit is Issued.My Workers �- 3' / ' �� Total
Compo�99/��_etiro��n I�nIs�urance c'a�rr�ier�aAn,d,�P�oli.cy��{p�u�m_sber are: 2�
Canlar.61k y PoucyN U `'��� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
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'Cempensebon Laws of Cali. All roofs shall be inspected prior to any rootirfg 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.
subject to thCE eOWorrkerss'Compelnsateor proovisionthis
s ofCertificate
Laborr Code,you mustufathwshould
ithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Ce reg U latonS.
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 slate laws relating to building construction,and All r Of Coverings t C SS°C"Or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spection purposes. rJ 9-7
(We)agree to save,indemnify and keep harmless the City ai Cupertino against liabilities, .Y�'1
of the granting of this permitses which may in any way accrue against said City In consequence SIGNATURE OF APPLI ANT 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 TrM CITf OF CUPER-12,10 BUILDLN(3 DEPART;IEV T
PRIOR TO ISSUANCE OF PEP,NNtiT ANID ,NSpE'CTION P:ASE.
1. Prior to pe mit issuance, you mus agree to comoty Nvith U.B.C. standards and r at ufacc ea sec's
on reroofing.
2. New roof coverings shall not be aoolied %vitheut first obtaining all inspec:icn and wricen acerevai
from the building in-e•_':or. A final in e non and anoroval shall be obtained from the building
inspector whoa the rercofmg is completed.
3. All types of roof shall be inspea:ed prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) Preinsaection or tear off approval.
2.) In progress in_s ection approvrl.
3.) Final ir=e---:ion aocrcval_
a.) Operable smoke der aor verification
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood nail inspec ion is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material dawn
"the sheathing and a building in_sceV or will in_�e^_,ail sheathing at that time.
E UNDERS?ARID Tt'F ABO`/E POLICY ON REROOF1
WIN
C PND WILL COMPLY �VITrl Tr.
POLICY
HO'Lv[EOWWcRS NANM:
e, , D ;roc SEu�s 2510 ` , �-cee,l(. (�) UGQ
ADDRESS;
REROOFING COMPANY NAME:
t t
APPLICANN+TS SIGNATURE:
CIT f OF CUPERTINO
BUILDNG DEPARTMENT
Remoflwinw6rd