R 5770 (2) ~ NUMBER R- 5770
APPLICATION FOR CITY OF CUPERTINO
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 ADDRESS
/OSGU ,5 toKP-s
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES [1 11 yes—I understand that a Class A
NAME/(a V&A-)' .at
assembly is required.
/ /J NO - Initial I.C.B.O.#
ADDRESS J O✓5-6 0 S Aa KPS IA" 10+ EXIS ING RQQlF QQYERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
//��
Oil= H TO BE REMOVED TO BE RETAINED
ADDRESS /� J /J TYPE OF ROOF COVERING
CITY&ZIP -5 7/ ��rT n�� /�` -� A. �'
EXISTING
PHONE /�d/ BUILT-UP ROOF ❑
NUMBER 47 NUMBER 40
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
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. /� WOOD SHINGLES
License Class Lie.Number�y��/4 `� -
Date-5%2r_3; 1? ContmctorA4K�� 6)=11//C' OTHER(SPECIFY) /
OWNER-BUILDER DECLARATION PROPOSED v04
I hereby aXirm 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
construct,alter,Improve,demolish,or repair any structure.prior to Its Issuance,also requires the BUILT-UP ROOF - ❑
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvlelon 3 of the
. Business and Professions Cotle)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 live hundred dollars($500).):
❑l,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 handed or offered for sale(Sec.7044,Business and Profas-
slonsCode: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 Cade:The Contractors 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 Contractors License Law. PROVIDE MFGR..INSTALLATION SPECS.
C]1 am exempt under Sec. ,B It P.C.for this reason
Owner Date APPLICATI T VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration: '���ss��//
❑I have and will maintain a Certificate of Consent to Performa for Workers Compensation, Building
as provided for by Section 3700 of the Labor Coda,for the petlormance of the work for which this y�pp�,y���� Qy
permit is lesuntl. WAY 28 19 ee Seismic
❑1 have and will maintain Workare Compensation Insurance,as required by Section 3700 Of
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's CITU
Compensation Insurance carrier and Policy number are: UI' (JVt.t t Ds Total
Carrier Policy No. PERMITAUTHORIZAT DATE
CERTIFICATEEN COMPENSATION
SURANMWORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I cenity that In the performance of the work for whim this armlt Is Issuetl snaaaIIII not employ
any person in any manner so as to become subject r atierfl W Cell All roofs shall be inspected prior to any roofing material being
fornla.`J� 1 A� installed. If a roof is installed without first obtaining an
Date; Appllcan inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption, should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In. -
spoctlon purposes,
(We)agree to save,Indemnity and keep harmless the City of Cupertino Against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence I NATO OF APP CANT
m the granting of this perms. 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
CITY OF CUPERTINO - BUILDING DEPARTMENT
RE-ROOFING POLICY
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and
manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections and written
approval from the building inspector. A final inspection and approval shall be obtained
from the building inspector when the re-roofing is completed.
3. All types of roofs 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. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
5. If plywood is installed, a plywood nail inspection is required.
• 6. If any roof is applied without first obtaining an inspection, you will be required to remove
all new material down to the sheating and a building inspector will inspect all sheating at
that time.
UYIPORTAiINT:
1. Flat roofs must have a ''/4"per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE POLICY.
HOMEOWNER'S NAME:
ADDRESS: n
RE-ROOFING COMPNAY NAME: Z'" %Ca )O=j^.17 S
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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