R 49760
OFFICE COPY
PERMIT R_ 4976
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE ANA
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YES E]If yes — I understand that a Class A
NAME _
roof assembly is required.
NO Initial I.C.B.O. N
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
ADDRESS
PHONE Z • 2
CONTRACTOR'S
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
BUILT-UP ROOF
PHONE
1 - ,� �
LICENSE
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NUMBERI�
ASPHALT SHINGLES
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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 Cade, and my license Is In lull force and.,
ellen. C l 1 C1 ��
Licen Cleaa Lic. Numbs r L`i
WOOD SHINGLES AUG2 p tggg�� J
Date Contractor
OTHER (SPECIFY). .
1.11 f UI- vvrL... u•.v
ER -BUILDER DECLARATION
I hereby afll that I am exempt from the Contractors License Lew for the folio Ing reason.
PROPOSED
(Sec. 703 .5, Business and Professions Cotle: 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
El
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter a (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Section by any ant for a permit sublecte the applicant to
oviolation tre
penalty
e civil penally of not mora thanpert floe hundred
hundred dollars ($5
WOOD SHAKES
with wage
❑I,k, owner sthe ture is not I tendedmy employeesred wages(Sec. their 744, compensation,ssand
for sale Business end Ponies.
o-
the work, and the structure la not Intended ores
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n owner4 f
License Law does not apply to an owner of property whooided t or
not builds
Impr Code: The , and who
Improves thereon, and who tloessuch work Nm&eaorthrough his own embuilding
V
WOOD SHINGLES
such Improvements are not intended or for leer. however, the of
lding rprovided ant
or Improvement
sold owner -builder ill en
Owner-bulltlarwlll have the burden of proving that he tlltl
pr
OTHER (SPECIFY)
not buiIs
ld or Improve for purpose
not build or Improve lar purpose of selaJ.
sale.).
❑ I, as owner of the property, am excluslvely contracting with licensed contractors to construct
the project (Sec. 7044, 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 Improve& thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
❑ I em exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Dale
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided by Section 3700 of the Labor Code, for the performance of the work for which this
Buil n
permit is lveued.
is issued.
❑ I neve and will maintain Workers Compensation
El &lion Insurance, as required by Section 3700 's
the Labor Code, for the
!�✓
Seismic
wo
pedormence of the work r which thI-�ermic Is lesuatl. My Worker's
Comp Insure a erriere
ollcy,numb are: J� I - I I�
/,
Total
Carrie Policy N0.
PERMIT AUTHORIN
DATE
CERTIFICATE OF E%EMPTI FROM WORKERS'
COMPENSATION INSURANCE N.C.o
(This section read not be completed If the permit Is for one hundred dollars ($100) or 1069.)
1 certify that In the performance of the work for which this permit Is Issued, I Shell net employ
All roots shall a inspected prior to any roofing material being
any person In any manner so as to became subject Id the Workers' Compenaatlon Laws of Call-
I
' +I,
installed. If a roof is installed without first obtaining an
Date llcant Ok,� r—�
inspection, I agree to remove all new materials for inspection.
NOTICE O APPLIC NT: Ii, atter making ihl6 Certificate of Exemtlen, you should become
subject to 1 e Workers' empen&allon provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply
pP ply with all non point
with such pi wisons or this permit shall be deemed revoked.
Source regulations. ,
I certify that I have read this application and slate that the above Information Is correct. I agree
to comply with all city and county ordinances and state Tawe relating to building construction, and
All roof coverings to be ch s "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
&pection purposes.
r
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costa and expanses which may in any way accrue against said City 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written 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 THE
POLICY
HOMEOWNERS NAME:
ADDRESS:.
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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