R 4963 PERMIT R_ 4963
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS /— ,Q
/ G 3 yn ny �jf / (� ` RESIDENTIAL COMMERCIAL OTHER-
OWNER's HAZARDOUS FIRE AREA
YES ❑ If yes—1 understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS �QY��I�'Q `' EXISTING ROOF COVERING
PHONE � U 1 1 / 73 NUMBER OF EXISTING COVERINGS O 11 e—
CONTRACTO
>( NAME �, TO BE REMOVED ✓I�— TO BE RETAINED
• ADDRESS /� /�� TYPE OF ROOF COVERING
CITY&ZIP s Y '/ I On'7/ EXISTING
L•tJ�'G
PHONE 0 BUILT-UP ROOF ❑
LICENSE
NUMBER sd F46 — ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensetl under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)01 Division 3 or the Business and Professions Coe,and my license is In 1 I force and
effect. WOOD SHINGLES ❑
License ClassLie.Number
Data 9r Contractor OTHER(SPECIFY) ❑
OWNER-BUILDERDECLARATION PROPOSED
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
canetrud,error,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed at to ant that he licensed pursuant to the provisions
oI the ss an Pro License Lew(Chapter 9(I ax enci'p om and 7000)of Division he 3 0l the
Business and Professions Code)or that he le exempt ih rom end the heals far the alleged ASPHALTSHINGLES
exemption.Any violation of Section 7031.5 by any eQPilcan le permit subjects the applicant to
a civil penalty of not more than rive hundred tloI a($600).f
C]1,asownerofthe property,ormyemplo�jBOB 4h we their sole compensation,will do WOOD SHAKES ❑
the work,end the structure Is giedaroffs d a ec.7044,Business antl Proles.
sten Code:Tha Contractor'sew o n �dn owner of property who builds or WOOD SHINGLESImproves thereonand who Co f o ugh hie own employees,provfded that
such Improvemenla ere not Intre or ale.Ir,however,the building er Improvement
is sold within one year of comp owner- IlBat will have the burden of proving that he did OTHER(SPECIFY)not build ar Improve for purpos ).
❑I,as owner of the property,erq,excluelvely contracting with licensed contractors to construct
the project(Sec.7j Business end Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner or property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B a P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT
I hereby affirm under penalty of perjury one of the following declaration: r a.y"
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, °' \U1.1nas provided for by Section 3700 of the Labor Coda,for the performance of the work for which thisg
Permit is Issued. 15 199�I have antl will maintain Workers Compenaetlon Insurance,as required by Section 3700 or f th Labor Cotla,for the performance of the work for which this permit le Issued,My Worker's'Compensetlon uranca carrier antl Polley number ere: 0072
C
arrier YI)Npg$y�q,3Y�14-0-' (i 1 `pERMITAUTHORIZATION DATE
CE FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is issued,I shall not em May
any parson In arty manner so as to become subject to the Workers'Compensation Lowe or tau- All roofs shall be inspected prior to a y roofingmaterial being
arnia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject
NOTICE
the Workers'Comperns Ile n previsionls ofethe11cateLabor Code,Exemption,
must forthwidthbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe 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 or this city to enter upon the above-mentioned property for In. .�-+
ape tion(We)
purposes. �_t J r
(We)agree costs save,Indemnity antl keep erml ay the Clry ai Cupertino y In con habitee e, C
oftlthe granting of this permiand tes which may in any way accrue against said Clry In consequence SIGNAT RE 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 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: PL
ADDRESS:- 1p 1,\
REROOFING COMPANY NAME: l S Lei v L
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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