R-5234 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5234
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DANS PERMIT ISSUANCE Ofl
180 WITHIN FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
��L/Cil /_/y--J
`b� (� I RESIDENTIAL _ COMMERCIAL OTHER
OWNERLS HAZARDOUS FIRE AREA
NAME V v"' 1 /� VES ❑ If yes s I undeassembly
is andreq that. Class A
root assembty Is required.NO ❑ Instal LC.B.O.k
ADDRESS c_J "'— EXISTING ROOF COVERING
PHONEx 2�% NUMBER OF EXISTING COVERINGS
CONTR R'
TO BE REMOVED TO BE RETAINED
NAM
ADDRESSn- TYPE OF ROOF COVERING
CITY 8 ZIP ejzn�Ls,
EXISTING
PHONE <
BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
ICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter B(commencing with Section WOOD SHAKES >l
]000)of Division 3 of the Business and Professions Code,and my license Is In lull force and l
effect' WOOD SHINGLES
Lican a Cl - Lic.Number
QTHER(SPECIFY)
Date cont ci - PRT
N RBUILD DECLARATION O
I hereby a Irm 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 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 Ei` A I D
. of the Contractor's License Law(Chapter g(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 .�� [�2 e MCI)
a civil penalty of not more than live hundred dollars($500).1:
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen
slons Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES CITY�Y CUF'tHIINU
Improves thereon,and"who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement _
is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct
�I �'
the project(Sec,7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO'
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B$P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, I Buildin6
asprovi for by SeMion 3]00 of the Labor Cotle,for the petormenea of the work for which ihl9
permit is issued.an Z"1 I J ismic I,
I have and will maintain Worker's Compen etlon Ineuranca,es requlretl by Section 3700 of I
t the Labor Code,for the performance of the k for which Wh d5.rmlt la Issued.My Worker's Total
Comp satl n Ina rents carr end Policy nu bar are: '}_>
Carder PoncyNQ._J '� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 4117 9
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued.I shall not employ
' npeerson In any ginner so as to become subject to thetWor(srs'cora enaason Laws of Call. All roofs shall be inspected prior to any roofing material being
�.I J)l installed. If a roof is installed without first obtaining an
Da ` Applicant ` inspection,I agree to remove all new materials for inspection.
subje ttCo th Workerss'Compensation provisions ofetheiflLaborr Code,yolu must fothwllitthcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All ro9PJLcpvehnos to)be cl s "C or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may In any way accrue egelnst 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 _
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDD;G DEPARTNIENT
PRIOR TO ISSUANCE OF PERK' 11T 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, an
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.
E UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH Tri
W
POLICY
o
HOlvIEOWNERS NAME:
ADDRESS:' f ,
REROOFING COMPANY NAME:
r
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APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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