R 5627•
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OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMBER R' 5627
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3'2'28- PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS Py 1,
COMMERCIAL ' OTHER
—.RESIDENTIAL
OWNER'S
HAZARDOUS FIRE AREA
/ p, / t /
S Yea A
YES ❑ Ilyes—Iundersfand Mata CII
NAME !J�/�!V
roof assembly is required.
NO Initial I.C.B.O. N
EXISTING ROOF COVERING
ADDRESS
.PHONE W 3'y
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
y� ��,
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS L
TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING'
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES , ❑
License Class Uc. Number
OTHER (SPECIFY) ❑e -
Data Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
(Seo. 7031.5, Business and Professions Code; 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 Contractor's Llcense Law (Chapter B (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
by any for a permit subjects the applicant to
Anyviolationo tmo of Section hundred
a
a man hundred dollars
ASPHALT SHINGLES w CGj�j'Aw�j')
Civil en. dapplicant($500).):
civil,snowy of not more ($Soo a
❑Irks owner property, or employees redo as Compensation, will
WOOD SHAKES
(Sec.theirsole
cturetnot I tendedmy
the work, end the structure le not Inse
structure r sale
or offered for eels (Sea Business antl Profes-
1 —
sions Low er of
uildsoimprCode: The Contractor's Licence Lew does s not apply to an owner of property who builds or
improves thereon, and who does such ware himself or his own employees, provided that
WOOD SHINGLES ❑
. It, how
oroffered for edea. n, however, the or Improvement
such Improvements are notcompletion,
lebIntended,
year of enbuildingr
issoldor
OTHER (SPECIFY) ❑
forpurposetofstheownarbulltlerwillhavetheburdenofprovingmethatlld
not build or improve for purpose al 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 Contractors License Lew.
❑ I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Ni'
owner AT10
WORKER'S COMPENSATION DECLARATION
ICATIO ATE
VALUATION PERMIT FEE
I hereby affirm under penalty Of perjury one of the folfowing declaration:
❑ I have and will maintain a Cenlllcete Consent to for Workers Olt
safe
of sell -insure Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
I
OF s�
Building
permit Is Issued.
L]1 have and will maintain Workers Compensation Insurance, as required by Section 3700 of
L
U~�%�T�s'
Seismic
,the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
'V O
Compensation Insurance carrier and Policy number are:
Total
Carder Policy No,
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(Thee section need not be completed If the permit le for ane hundred dollars ($100) or lose.)
I certify that In the performance of the work for which this permit Is issued. I shell not em May
in become �an-
any perean any manner do es to subject to the Workers' Compenekllon Laws of
All roofs shall be inspected prior to any roofing material being
i°`nla.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE
he WTO orkers' Compensation provisionis of theftale of Labor Code, Exemption,
sub ecct to mus uorthwshould
ith comply
Applicant understands and will comply with all non point
with such provisions or this permit dhall)be deemed revoked,
source regulations, '
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 roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-spe
on purposes.
_ _ /e; `
(Wel agree to ander Indemnity and keep harmless the City a ai Cupertino against liabilities,
judP costa and which may In any way accrue against geld City In consequence
y/'K'/�iVAl Q
SI NAT E OF APPLICANT DATE
of thmena,
of the granting of Ihle permit.
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
El
•
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPAR71MENf
PRIOR TO ISSUA`ICE OF PER 9T AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacrurers 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,) P:einspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke dete^_:or verification
b.) Spark arrestor insallation
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 TTM
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTNO
BUILDING DEPARTZIE`1T
Rerooflwinwdrd
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