R 5283 (2) PE
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5283
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI100 DANS FROM UST CALLED INSPECTION.
BUILDING ADDRESS /
(Q 5 [ L so/) D�l RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes-I understand that a Class A
NAME -L -A roof assembly is required.
NO '43� Initial I.C.B.O.W
ADDRESS &9;e-,A- 4=- EXISTING ROOF COVERING
PHONE t7`J j �Jfp 23 NUMBER OF EXISTING COVERINGS 110,
CONTRACTOR'S
TO BE REMOVED 4�TO BE RETAINED
NAME 4�?o .„,q /SSflC��
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP_/ Z � !!/r'0� /�L-C-C_J
e _ 6G 5/ 7 EXISTING
PHONE— Y BUILT-UP ROOF ❑
LICENSE
NUMBER —3- G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of a Business and Professions Code,and my license Is In full force and
exam. r J WOOD SHINGLES
License Class Uc.Number / /
Date cont actor OTHER(SPECIFY) [ �
ER-BUILDER DECLARATIO PROPOSED
I hereby affirm that I em exempt from the Contractors Lice Lew for the following reason.
]031.5,Business and Professions Code: Any city or my which requires a permit to
construct,alter,Improve,demolish,orrepair 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 ssContractors License Lew(Chapter S(commenting with Section 7000)of for the 3 0l the
Business end violation of Cede)or that he Is exempt therefrom and the beets for the alleged ASPHALT SHINGLES '
exemption.Any violation of than
five 7031,5 by any applicant for a permit subjects the applicant to 8g��,,
e civil penalty of not more then five hundred dollars($500).): r'
El 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES AID ❑
the work,and the structure is not intended or offered for sale(See.7044,Business and Profes. �/,�,a,,p.,)
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHING44V 2ly ElImproves thereon,and who does such work himself or through his own employees,provided that ff➢➢
such Improvements are not Intended or offered for sale.If,however,the building or Improvement �q,
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(S t:I%- ❑
not build or Improve for purpose of sale.). LIU,
❑1,as owner of he property,am exclusively contracting with licensed contractors to construct
the Project(Sec.]044,Business and Professions Code:The Contractors 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 Contractors License Law. PROVIDE MFG R. INSTALLATION SPECS,
El am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and.111 maintain a Certificate of Consent to self-insure for Worker's Compensation, ��I���,,,���,,,,,,,��� ///��� ��w
as provided for by Section 3700 of the Labor Code,for the performance of he work for which thisatIORIZATION
,(�)//q/ �1 BW
permit Is Issued. P�V�/ re'USer{SR11C[I Ihave and will maintain Workare Companaetion Insurance,es requlretl by Seetlon 3]00 of„the Labor Cotlahi panic mance of the work for which this permit is issued.My WorkersCompensation I sura a ca er and P”number are: Total
//�/ / t DATE
Carrier r <r � Policy No.
CERnFICATE OF EXEMPTION FROM WORKERSOO9/❑ 2
COMPENSATION INSURANCE N C
(This section need not be completed If he permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued I anal)not am Jay
any person in any manner so as to become subject to the Workers'Compensation Laws of nfi. All roofs 9halIF10116 irlspected prior to any roofing material being
tornla. installed. If a roof is installed without first obtaining an
Date Applicant Inspectiopelgree to remove all new materials for inspection.
,NOT
subject 1t.the Workers'Compensation provisioafter makinns ofsiheflLabocate rCode,Exemyolu mustuforthwithshould bcomply ecome Applic t understands and will comply with all non point
with such provisions or this permit shalf;be deemed revoked. sour regulations.
I certify that l have read this application and state that the above Information is correct.l spree /
to comply with all city and county ordinances and stale laws relating to building construction,and All Oct �s be class"C”or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said Ctiy In consequence
of thegranting of this permit. SIGNATUR FAPPLICANT DA
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: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPAR'T'MENT
PRIOR TO ISSUANCE OF PERbIIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufac:ure:s re--'s
an re:cofing.
2. New roof coverings shall not be applied without first obtaining all inspection and wriren approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
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 detector verification
• b.) Spark arrestor installation
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 sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TAB
POLICY
HOMEOWNERS NAME:
Gj �itrSd r ��
ADDRESS;
REROOFING COMPANY NAVE: S
A.PPLICAVTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
I •
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