R 5037 PERMIT R_ .5037
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
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
J V -7-77 F19 IeA L Lo NF b,,e RESIDENTIAL_" COMMERCIAL OTHER
OWNER'S �I HAZARDOUS FIRE AREA
LE V Ot YES n If yes—I understand that a Class A
NAME mor assembly is require
NO n#ial I.C.B.O.#
ADDRESS / L) -2 F�,e4 4-e`wue D',e EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S`//'
NAME_ d'"��/'✓P UVJ F�'JG TO BE REMOVED TO BE RETAINED
7 ADDRESSr / 6,�. gl r�e,+rwr7 EXISTINGTY E OF ROOF COVERING
CITY&ZIP q /
PHONE /J �d 777 7 3 T BUILT-UP ROOF
LICENSE ❑ /
NUMBER $- (� 30 ASPHALT SHINGLES UAgC/`
LICENSED CONTRACTORS DECLARATION - ` _
I 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 is in lull force and
effect. ^
, o WOOD SHINGLES p
License Cleve 39- �, Uc.Number nn C
a i z- `/6 �J a OTHER(SPECIFY) Q�YG 12
Date Contractor
OWNER-BUILDER 6ECLARATION PROPOSED
I hereby affirm that l em exempt from the Contractor's License Law for the following reason. Tx
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ' r �� til...,,, l
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 License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
• Business and Professions Coda)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($500).):
E]1,as owner of the property.or my employees with Wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or th rough his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the buliding or Improvement
is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
nor build or improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed convectors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O, REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.IN$TALLATION SPECS.
[]I am exempt under Sec. ,B B P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and.111 maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit le seed. Seismic
eves end will maintain Workers Compensation Insurance,as required by Section 3700 of
_the Labor Coda,for the performance of the work for which this permit Is Issued.My Worker's 1 0�1 Total
Compensation Ineyrence carrier and Policy number are: l 7
Carrier ��' F(ti � Policy No. ( PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] \�
(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 employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Coll- All roots shall be inspected prior to any roofing material being
fornin. J installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cortlflcelo of Exemption,you should become
subject to the Workam'Compensation previsions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalGbe 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 ell 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-
epectian purposes. �7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, "0
judgments,costa and expanses which may in any way accrue against said Ciry In censequsnca
• 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
OFFICE COPY
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BUILDING DEPARTNIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must a,ee to comply with U.B.C. standards and manufacturers specs
on reroofing.
2. New roof coverings shall not be applied wit
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 muse 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 CONIPLY WITH THE
POLICY
HOMEOWNERS NAME: '
ADDRESS:
REROOFING COMPANY NANIE:
(�LPJ
APPLICANTS SIGNATURE:
CITY OF CUPERTNO
BUILDING DEPARTMENT
Reroof/winword