R-5507 (2) PERMIT
APPLICATION FOR clrY of cuPERrwo
NUMBER R- 5507
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 ADDR�ESSSS ry/ /_ ✓
4>45-1 VQ` ��j �L+L�/� RESIDENTIAL COMMERCIAL OTHER
OWNER'S N HAZARDOUS FIRE AREA
/j_ YES ❑ II yes—I understand that a Class A
NAME `�Y�Y �'�Y'7 roof assembly is required.
NO ❑ Initial I.C.B.O.W
ADDRESS /0Jy /G /�'� EXISTING ROOF COVERING
r PHONE 7`7 — Z V NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S p /
NAME TO BE REMOVED v TO BE RETAINED
� G. F-!/OG/.✓L/
A ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIPS
EXISTING
PHONE BUILT-UP ROOF - ❑
LICENSE �Z?J
NUMBER 9 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIARATION
I 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 full force and
effect
El7Z?fc/9 WOOD SHINGLES
License Claes III Number
16—�9'J ,e G Qao</.r/ OTHER(SPECIFY) ❑
DateContractor
OWNER-BUILDER DECLARATION PROPOSED
01
hereby affirm that I am exempt fromns the e: Any
or county
Lew for the fallowing reason.
coos.construct,
It Business and demolish,
or re Code: Any city or county which requires a permit to
construct,alter,Improve,demolish, n repeat any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit License flaw a signed statement that he la licensedctio pursuant to the provisions 1
of the Contractor'sstonLew(Chapter 8(commencing with Section 7000)01 Division ale the
exemption.
and Professions Coda)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemppen.Anyviolation ofhan Section five
byany applicant for a permit subjects the applicant to
e civil penalty of not more then,or bunmpl dollyeears(h wag): WOOD SHAKES❑I,as owner of the property,Is n or to employees with wages as their sole compensation,will s. ❑
the work,and the structure Is not intended or offered for sale(Sec owner
of property
end builds
o-
Imnovesth The,an who
License Lawdoes or app
throuo an gh
own
ployees,who
rovidedaor WOOD SHINGLES ❑
Improves thereon,end who tloen such work redforhimself or through however,
own employees,improvement provided that
such Improvements are not completion,
the
offered for sale.I(have the the burden of
pr oroiImprovement (SPECIFY)
is notsold build
Improve
for purpose
sale.).Owner-bulltlerwlll have the buNen of provingthat hadid OTHER SPECIFY 11Jy c.Lr ^{L�
not build or Improve for purpose of sale.).
C]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 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APP I ATE VALUATION P T FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
a
11 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUII g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is I tea. AUG 0 REC`Q �Q Z/ Seismic a
eve and will maintain Worker's Compensation Insurance,as required by Section 37W of T-��
the Labor Code,for the performance of the work for which this permit is issued.My Worker's )r l Ur r ur u / Total
'Compensation insurance carrier and Policy number are: V t f{))�'
Carrier �t/�✓, PolicyNo`: 7�—��4Of/0-9G PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' J41 I.
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit Is for one hundred dollars($100)or leu.)
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'Compensation Laws of Cell. All rool shall bEllinspected prior to any roofing aterial being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
DI.t e APPLICANT: a eater making This t the
of Exemption,musttforthwiitth comm) Applicant understands and will comply with all non point
subject C the Workers'D T. It,8ater kinglons of the Labor Code, comply
with such provisions or this permit shall be 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 r0 era 51 I er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. Q 7
(We)ts,co m save,indemnity and may I harmless wa the City a of Cupertino against I0'....c. D
judgments,costs and expenses which may In any way accrue against said Clry In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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: R-ROOFD;G POLICY FOR TI-1E CITY OF CUPERTNO BTJT DNG DEPART;LENT
PRIOR TO ISSUANCE OF PET�NIIT AND NSPEC'I t ION P!i-\SE.
1. ce, you must agree to comply with U.B.C. stand rds and man
Prior to permit issuanufarsrea sec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all i=ec:ion and wrren acuroval
from the building inspr_:ar. A final irtscecaon and aooroval shall be obtained from the building
incec-cr when the re:eofing is comole:ed.
3. All types of roof shall be inspe--,cd prior to any roof cern-.installed.
4. In order to receive a final,you trust complete steps I,2, and 3.
1,) Preinspection or tear off approval.
2.) In process inspection approval.
3.) Final insperion approval.
a.) Operable smoke det.ec:orve incation
b.) Spark arrestor installation
• 5. . If plywood is installed,a plywood nail inspec ion is required.
6. If any roof is applied without firs-,obtaining an inspection, you will be required to re aove all new
material down to the sheathing and a budding inspe .or vvul ince all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING PS1D WIIL COvIPLY NV=- Tr^-
POLICY
EOMEONWcRS NAME: /�ii✓ (�j i L. /y
[ �O�.S/ `��ii�iG (i/• Gly'
ADDRESS:
REROOFING COMPANY NAME: 4e
APPLICANTS SIGNATURE:
CIT!OF CUPERTINO
BUILDCNG DEPARTNINT
• Reroof/winwdrd