R-5605 (2) I
APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIRR- 5605
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS y
1D.SZ � CAI �� RESIDENTIAL--X—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
S YES ❑ If yes'—I understand that a Class A
NAME 7 .) roof assembly is required, -
NO Initial I.C.B.O.N
ADDRESS r�L7 Z /dS cc,it EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR' // /J
NAME � ! i,1 SLI /C�- TO BE REMOVED X TO BE RETAINED
ADDRESS ?, — TYPE OF ROOF COVERING
CITY&ZIP / e— A.Z3CGtiztr3 '
EXISTING
PHONE �23 G/S BUILT-UP ROOF ❑
CENSE
NUMBER F ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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 lull farce and
effect. ❑ _--_-___--�
WOOD SHINGLES
License Cesse-39 Lic.Number /
OTHER(SPECIFY) ❑
Dale6' 197 Contract
OWNER-BUILQK DECLARATIO PROPOSED
I hereby affirm that I am exempt from the Contractor's Llcenae Lew f the following reason.
(Sec.7031.5,Business and Professions Coda: 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 Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvlslon 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
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
C]1,as Owner of the property,or my employees with wages as tholr sole compensation,will do
the work,and the structure Is not Intended or Offered for sale(Sec.7044,Business and Profes-
Mons 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 ❑
such Improvements are not Intended or offered for sale.ll,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 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 III INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APP,t'1,C T DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one Of the following declaration: 1
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, I /J� Building
as provided for by Section 3700 of the labor Coda,for the performance of the work for which lhie W p l
permit is issued. //�� v /t $eISmIC
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 OP1 //,� 6 �r.
_the Labor Code,for the performance of the work for which this permit Is Issued.My Workers V�- `'uh; c� lI /-s /O6,' Total
Compensation Insurance carrier and Policy number are: rr1T.n .../T
Carrier Policy No. PERMI`f AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(]
(This section need not be complet/thOperMit Ift I or one ndred dollars($100)or less.)certity that In Iha performance ofthI mIi is Issuetl. shell not employ
any person In any manner so as to ba the are'Compensation Lewis of call. All roo shall be inspected prior to any roofing material being
forma. pp>� installed. If a roof is installed without first obtaining an
Appinspection,I agree to remove all new materials for inspection.
NOTICE' APPLICANT: It,afterertlllc of xemption,you should become A licant understands and will coin I with all non oint
subject to the Workers'Compensatiothe or Code,you must forthwith comply PP comply P
with such provisions or this permit shalCbe deemed revoked. source r!9,4ations.
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 r Erin o CIas or b
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. p
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
fill judgments,casts end expenses which may In any way accrue against said City In consequence IGNATU E OF LI NT DATE
of the granting of thisand permit.
PRE-INSPECTION: PLYWOOD: -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 THE CITY OF CUPERTO BUIIDNG DEPARi�CENT
N
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PILkSE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufactures rep's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
-tion and aooroval shall be obtained from the building
from the building inspector. A final inspe
inspector when the rerooFng is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you mu-a complete steps 1,2, and 3.
1,) P:einscection pr tear off approrl.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
6. If any roof is applied without firs:obtaining an inspection, you will be regttired to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that time.
AVE UNDERSTAND TrM ABOVE POLICY ON REROOFING PND WILL COMPLY WITH TrtE
POLICY
I:orviEowNERs NAME: occ
05 v ccr P/
ADDRESS-.,
REROOFING COMPANY NAME: �n
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/winward