R 5245 PERMIT
APPLICATION FOR CITY OF CUPEFTINO NUMBER R_ 5245
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
IN DAYS FROM LAST CALLED INSPECTION.
V `^OI IA _`•
"1 1 V` `!•/IT RESIDENTIAL COMMERCIAL OTHER
OWN R'S HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
r — NO Initial I.C.B.O.Al
ADDRESS— G`OU EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS L TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
WOOD SHINGLES Cl
License Class Lic.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECIARATION PROPOSE
I hereby affirm 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,Biter,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 Lew(Chapter 8(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.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,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 Intended or offered for sale(Sec.7044,Business and Proles.
along 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.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) ���'''777
not build 1,as
Improve ler purpose of sale.).
❑Lee owner of the property,am exclusivelycontracting Code:
T with Contractor's
contractors to construct
the project(Sec.7044,perty Business hentlProfessionsCotle:TheandwhoconrctsfaLewtlroenot PROVIDE LC.B.O. REPO
apply to c ntownerof property who builds orImprovesContractor's License
and who contracts for such protects ��,}�
with a am exempt
licensed pursuant to the Contractor's uonae Lew. PROVIDI0�.II A
�J I em exempt untler Sec. ,B 8 P.C.for this reason
owner Deta APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hl oilrm untler penalty of perjury one of the following declaration; pp�T,, n
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, P E BILI In
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is Issued. �� eISn11C
1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of ff f/y� ®g .
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's �J s6
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. MITT-( T IZAT10N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE �0 4
(This section need not be completed It me permit Is for one hundred dollars($100)100)o or less.) to I certify that In the performance of the work for which this permit Is Issued,I shall not employ
6 any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICbecome
subject to the WoTO rkers'Compensatlonafter mppeoNeloos oeheficate of Laborr Code,Exemption,
mustufothwlith comply Applicant understands and will comply with all non point
with such provisions or ibis permit ehall+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 for In.
spection purposes.
(Wel agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
ludgmente,costa antl expenses which may In any way accrue against said City In consequence
onhegrend" this permit. IfIGNATURE 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
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.H.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
HOivIEOWNERSNA.E:
ADDRESS:. I 1 �' W1/I/l `� t • C�µO
REROOFING COMPANY NAME: Jf'
APPLICA147S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTZAENT
•
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CITY OF CUPERTL O
BUILDING DMSION 408-777-3223
RE-ROOF TEAR OFF POLICY
1. You must schedule an inspection for the tear off the day before the date you wish the inspection to be
made. The procedure is to call the Building Division(777-3223)between the hours of 12:30 and 4:00
p.m for nest day inspection.
2. When the roof is tom of; the nails removed or driven in and all of the dry rotted wood has been
replaced, THEN YOU MUST CALL THE CITY BUILDING DIVISION. An inspector will be
notified that the roof is ready, and he will respond to do the inspection as soon as his schedule will
allow. There are special hours for this service betwi=n 8:00 a m. and 11:00 a.m., and between 1:00
and 3:00 p.m.
• IF YOU CALL FOR THE TEAR-OFF INSPECTION AND THE JOB IS NOT READY, THERE WILL
BE A RE-INSPECTION FEE OF $69.00 CHARGED, WHICH MUST BE PAID BEFORE
ANOTHER INSPECTION IS MADE.
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