R-5566 (2) PERMIT
APPLICATION FOR f� OF CUPERTINO NUMBER R- 5566
U E(.TI�N DIVISION PERMIT EXPIRATION
REROOF PERMIT 4OB)]7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS )
14313 'ion �'�� RESIDENTIAL COMMERCIAL OTHER
OWNER'Srr HAZARDOUS FIRE AREA
—H � 1 V t`/u y1 Q p YES E] If yes-I understand that a Class A
NAME I ` roof assembly is required.
AL1 NO % Initial I.C.B.O.k
ADDRESS I 13 f�J_`,,,y-, f �'7 L,-1 Qom/ I EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRA9IQR'S n
I}�U� ` , y I�-/ TO BE REMOVED TO BE RETAINED
NAME Jf J Th '\ 1 lD
ADDRESSf� �\ PE F ROOFCOVERING
CITY&ZIP - Z �'/ +-� ". �5L
- \ �} r EXISTING ,
PHONEyi J ( , 3 '- Y� , BUILT-UP ROOF E-1Y
LICENSE - ❑
NUMBER S (oS`�-�� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Q' /
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and O✓/{yTo�
effect.
C 3 q 5L �3__1 WOOD SHINGLES El /
License Class Llc.Number `
Data g — ) -q 1 Contracfor t��'Y^-��� (—` OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's 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 lChapler,9(commencing with Section 7000)of Division 3 of the
Buell 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
e civil penalty of not more than live 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 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 ❑ r t
such improvements are not intended or offered for sale.It,however,the building or Improvement
Ie sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)—
e I
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 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 contractogs)licensed pusuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
Owner
em exempt under Sec. ,B 8 P.C.for this reason
owner oats APPLI TON DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's 00 Compensation, p',-
as provided for by Section 37of the Labor Code,for the performance of the work for which Il la q(* p Building
permit Is issued. �p �� BeISmIC
have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 C/ Y
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's
Compensation insurance carrier and Policy number are: OF 1411-4 Total
Carrier S t`t-'t-<
\-L Fol 1-�> Policy No. I Z� 3�7 PERMirAUTHORiZATION 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.)
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 became subject to the Workers'Compensation Laws of Call- All roofs sVaWbEfinspected prior to any rocifing mater al being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE TO become
subject Ito the Workers'C Compensation proviNT. It,after sionis ofetheiLabor Code.Exemption
ou musufothwshoulith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. LIT Ce regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All f coverings to be classo better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
sp(We) purposes. 1 c�^ 1 -
(We)agree to save,expenses
and keep harmless the City ai Cupertino against Ilebllence I
judgments costs and expenses which may In any way accrue against said City In consequence
of the granting of this Parma, 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
T'
• SUE1rCT: REROOFING POLICY FOR T•r:E CITE OF CUPER INO BUTT DIING DEPA.RT`AEN+T
PRIOR TO ISSUANICE OF PERMIT AND NcPE' ii ION P!? SE.
1. Prior to permit iss[once, you must a_ee to comoly with U.B.C. stand
and m rufacmrers s ec's
on rercofine.
2. Ne•.v roof coverings shall not be applied :vithcu[ first obtaining all inspection and :urine.^- approval
from the building tion A final tn-Pec:ion and approval shall be obtained from the building
insoec:ar when the rereonng is comole:ed.
3. All types of roof shall be ince=:ed prior to any roof being installed-
4.
nstalled4. In order to roive a final,you must complete ceps 1,2, and 3.
c-c
1,) P.--. s=r_don or tear off approval.
2.) In progress inspection apprc�-J.
3.) Final inspe:ion approval.
a.) Oce able smoke de:r:or ver union
b.) Spark aae-stor installation
• 5. . If plywood is installed,a plvwced nail inseatioa is required.
6. If any roof is applied without first oota[mng an [rope='tion' you will be required to remove all ne:v
material down to the she thing and a building inspector wiil inspear all sheathing at that time.
AVE UNDERSTAND THE AEOVE POLICY ON REROOF NG PND WIT-1 COMPLY WITr_ Tr',
POLICY
FiOMEOWNERS NAME:
ADDRESS:_:
REROOF u IG CObfPANY N.�..�[E:
APPLICAIN 7S SIGNATURE:
CITY OF CUPERTINO
BUILDING DE?AR'Iti(ENT
• Rerooflwin:vard