R-4827 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB RR- 4827
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
_7�? —�'CJ��' / v \ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-1 understand that a Class A _
NAME - :, =assembly is required.
NO ❑ Initial I.C.B.O.N
-7
ADDRESS �- -2yD.
, y�-ZC;-+ Skv�Y. �' C� RS/St-I EXISTING ROOF COVERING
1y-7 O
PHONE y V� —ZOO'--) ) NUMBER OF EXISTING COVERINGS -�
CONTRACTOR'S
NAME ' q� t ler I` TO BE REMOVED TO BE RETAINED
I Oex '✓LG
ADDRESS r TYPE OF ROOF COVERING
CITY&ZIP J�S ,�..-,r`~ EXISTING
PHONE— f �7' �` Sdd BUILT-UP ROOF
LICENSE
NUMBER �- ' ASPHALT SHINGLES ❑
LICENSEDCONTRACTORS DECLARATION ❑ J�
hereby affirm that em licensed
underunder previsions of Chapter 9(commencing with Section WOOD SHAKES
and
/
]000)of Division 3 0l the Business and Professions Code,and my license Is In lull torte entl
effect' ^ WOOD SHINGLES E]�
License Class ` Lie.Number li
❑
Date Centre OTHER(SPECIFY)
OWNER-BUILDER DE LARATIO PROPOSED
I hereby affirm that I am exempt from the Contract Law for the following reason. p- .'
(Sec.7031.5,Business and Professions Code: Any dly unry which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF -ql—q4/L
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions C//y %
at the Contractor's License Law(Chapter 9(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 violationof$action7031.5 by any applicant for a permit subjects the applicant to C_
a civil penalty of not more than five hundred dollars($500).1:
❑ WOOD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ �•
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Cc de:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El �•
Improves thereon,entl 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 VLA -�
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) r
not build or improve for purpose of sale.).
❑I,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 Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
r WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: _ q`�•-� /p•h
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 5 / TBuilding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this , 1 I
permit is Issued. I( 7,4
�• Seismic
.have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / Q
-the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total /�
Compensation Insurance carrier and Policy number are:
Carrier �L' - -(""A Policy No���+Zy '9� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[3
(This section need not be completed 11 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
any parson I any manner so as to become eu ork 6e ,penaaI L Na of Cali. All roofs shall be inspected prior to any roofing material being
fornix __ installed. If a roof is installed without first obtaining an
Date S s App inspection,I agree to remove all new materials for inspection.
subject Ito the w«kers'Compensation UCANT: If,after pro• Ions of bet`s oro Code,yoExemption,
u must forthwishould
thbecame
c comply Applicant understands and will comply with all non point
with such provisions or this permit shaMbe de ad. source regulations.
I certify that l have read this application and slate that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All r Rgfr a class"C"or better.
hereby authorize representatives of this city 10 enter upon the above-mentioned property for in- /
spection purposes.
(Ws1 agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, r
judgments,costs and expenses which may in any way accrue against said City in consequence SI TORE APPLICANT DTE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: RF-ROOFING POLICY FOR THE CITY OF CUPERTENO BUI DLtiG DEPARTMENT
PRIOR TO ISSUA`ICE OF PERMIT AND INSPECTION PF--QE.
1. Prior to permit issuance, you must agree to comoly with U.B.C. standards and manufacntrers sec's
on reroofing.
2. Newroof coverings shall not be applied without first obtaining all inrec:ion and wriren approval
ect on and approval shall be obtained from the building
from the building inspector. A final insp
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 de,.e^_:or verification
• b.) Spark arrestor installadon
5. If plywood is installed,a plywood nail inrection is required
6. If any roof is applied without fits[ootaining an inspection, you will be required to remove all new
ing inspector will inspe_t all sheathing at that time.
material down to the sheathing and a build
NVE UNDERSTAND TFIE ABOVE POLICY ON REROOFING PND WILL COMPLY W= TSE
POLICY
HOMEOWNERS NAME: J `
ADDRESS:
0
REROOFING CON[pANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTLVIENT
•
Reroof/winword