R-5637 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5637
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
I
W
' THIN DAYS PERMIT ISSUANCE OR
WDANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS�j7
RESIDENTIAL COMMERCIAL OTHER
OWN R' � / HAZARDOUS FIRE AREA
C� vs–Y VES oyesss assembly
is reqand that. Class A
NAME l.i ��"ZZ// roof assembly is required.
,,.G NO Initlal I.C.B.O.a
ADDRESS /G,5L- EXISTING ROOF COVERING
PHONE 370
2 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
VAME fi C TO BE REMOVED 70 BE RETAINED
ADDRESS TYPE OF ROOF COVERING
cl7v s ZIP—
EXISTING
(�c"��X�> EXISTING
PCP 1J / ` _ BUILT-UP ROOF ❑
LICENSE i J ASPHALTSHINGLES ❑
NUMBER
LICENSED CONTRACTORS sof Chapter 9(N
I hereby iaffirmnion that 1 em licensed under provisions of Chapter 9(commencing with Section
WOOD SHAKES
]000)of Division 3 0t.the Business and Professions Code,and my license is In full lone and
effect. b WOOD SHINGLES ❑
License Class —� Llc.Number
Date 2 contractor ��/�,� OTHER(SPECIFY) E]OWN R-BUILDER DECLARATION C11 PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew 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]000)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-
sions Cotle: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
impres thereon,end who does such work himself or through his own employees,provided that (/l
sucIn 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 p pp
the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. / 7
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.
❑I em exempt under Sec. ,B&P.C.for this reason
Owner Date Am�tail)rTbATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, w �(� Building
s as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q a/M V
permit Is Issued. PPR SBISn11C
r ❑ have entl Int W er's Comp s on Insurance,as required by Section 3700 of (t J /Yn CC(
the Labor Cod ,for the a o ca of 1h work for whi thls permit is issued.My Worker's Y VUrtN
'Campensatlon sure a ler entl Poll number ere: (,y(��J/� 7 11y Uf Total
' Carrier '� Policy No. l.� ( 7L 6 PERMIT AUTHORIZATION DATE
CEP[i 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.)
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 roots she b2 1 spected 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 A a understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P P Y P
with such proviSions or this permit she@be deemed revoked. s urce 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In. i
spection purposes. Q
(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
of the granting of this permit. SI TU FAP (CANT 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: RE-ROOFING Tr_
OOFING POLICY FOR E CITY OF CUPERTINO BUILDDiG DEPP.RT1 LENT
PRIOR TO ISSUAINCE OF PERMIT AND INSPECTION PILASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufaca rets spec's
on reroofing.
2. Ne•.v roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and acoroval shall be obtained from the building
' inspector when the reroofing is cpmoleted.
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.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke de,.—..or verification
• b.) Spark arrestor installation
5. If plywood is installed, a plywood[tail 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 inspe^_:or will inspect all sheathing at that time.
WE UNDERSTAt`!D THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITr. THE
POLICY
� S
F:OMEOWNERS NAME:
ADDRESS;
REROOFING CObIPANY NAME:
APPLICAIN7S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/wimvord