R 4881r
nFFIrF rnpv
NUMBER R' 4 8 81
APPLICATION FOR CITY of cuPERTINo
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
{/�
`\y_
rJ l�
RESIDENITIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
YES ❑ If yes— I understand that a Class A
NAME
roof assembly is required.
Initial I.C.B.O. If
/ e� U�
EXISTING ROOF COVERING
ADDREss ✓ ' ��f /
%�
6` cc
NUMBER OF EXISTING COVERINGS
PHONE
)
TO BE REMOVED _L TO BE RETAINED
CONTR
0 0 r
NAME vv V
ADDRESS ^ ,
TYPE OF ROOF COVERING
(
CIN 8 IF C.7�MD,V
EXISTING
501q /
-
PHONE "Q.
BUILT-UP ROOF - ❑
cC?9,§--
CENSE
NUMBER p V^ J d
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby afilrm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professlohe Code, and my license Is In full force and
effect.
WOOD SHINGLES ❑
-3 9
License CILIS Lla. N u
'
Q 47J%(f
OTHER (SPECIFY) ❑
Date Contractor _
PROPOSED
OWNER -BUILD DECLARATION O
I hereby affirm that I am exempt from the Cc tor's License Law for the following reason.
tSec. 7031.5, Business and Professions Code: city or county which requires a permit to
construct,alter, Improve, demolish, or repair any air To, prior to Its issuance, also requires the
applicant for such permit to file a signed are m th a litllcensed pursuant to the provisions
BUILT-UP ROOF ❑
of the Contractor's License Law (Chapter 9 ommenc tN Section 7000) of Division 3 of the
Business Professions
and Code) or tryal'h0 a rh fr§n and the basis for the alleged
A
exemption. Any /n
ASPHALT SHINGLES ❑
'notatio4fStl n 7031.6 n p ant
permit aublacte the applicant toe cryll emptien.
0l not mfhuntlr I 0)J:❑
I, as ownerof ther my with wages as their sole compensation, will do
WOOD SHAKES
the work, and the etrucI d oroffered for sale (Sec. 7044, Business and Proles -
alone Code: The Contf�l1s does not apply to an owner of property who builds orWOOD
SHINGLESImproves
Ihareon, en Su ark himself or through hie own employees, provided that
such Improvementgg ereed or offered for sale. If, however, the bulltling Improvement
or
Is sold within one ybar of 61rnp14tlon, the owner-bulider will have the burden of that he did
proving
not build or Improve lorpurpose of sale.).
OTHER (SPECIFY) ❑
❑ I, as owner of the property, em exclusive 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 Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt under Sec. ,B 8 P. C. Mr this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
—_1___ALUATION
PERMIT FEE
I hereby affirm under penalty at perjury one of the fallowing declaration:
[21 have and will maintain a Certificate Consent to for Worker's
A�
of eelFinsure Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Is issued.
4
Buildinm
permit
�
E]Seismic
have and will maintain Workers Compenaetlon Insurance, as required by n 3700
the Labor Code, fart performance of the work for which this permit Is Issued.
tl. MyMy Workerl Ee fff
A�
z'1 1
'Compene m a ca Polls nu are: 1 , / zs // k
,A
Total
End
sI Y Y�UY Jr
/
�N�PERRM AUTHORI=ON
DATE
Carrier Policy No.
CE IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CC]
(This section need not be completed If the permit Is for one hundred dollars (5100) or leas.)
776C/
1
1 certify that in the performance of the work to which this per t Is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become aub 1 to the Worker Compensation Laws of Cali.
fornia.� Y `Q�/ r
kpplicent
installed. If a roof is installed without first obtaining an
Date /j
inspection, I agree to remove all new materials for inspection.
subjectloEheeWTO orrkerns'Comperreello provisionasoftheflcate of LaborCode,yolumustuforthwlltlhbecome
omply
Applicant understands and will comply with all non point
with such provisions or this permit shal@be deemed revoked.
source regulations.
I certify that I have read this application and Stale that the above Information Is correct. I agree
to comply with all city and county ordinances and elate laws relating to building construction, and
All rOoverings to class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes,
r /
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
, J d Y
judgments, costa and expenses which may In any way accrue against said City In consequence
Of the granting of this permit.
SIGNATURE 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
nFFIrF rnpv
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. Uplywood 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
Reroof/winword