R-4643 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 46 4 3
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
RESIDENTIAL COMMERCIAL OTHER
OWN 's HAZARDOUS FIRE AREA
VES ❑ Ii yes s I mblyisrunderstand that. Class A
NA AU f roof assembly is required.
NO Initial LC,B.O.H
ADORES Z 1? A/OA/sPA/ C-7' EXISTING ROOF COVERING
PHONE 1SS-- O r 'y NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
�f�2� D�E�7L /J_�. ,v TO BE REMOVED S TO BE RETAINED
( ���!
ADDRESSTYPE OF ROOF COVERING
CITY a ZIP �L! i N/ ,Q/i`� GII Gib
//moi grafi EXISTING
PHONE (��r 8'�$ - 3Ys"f! BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under pontoons of Chapter B(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 El
License Claes G _ Up.Number 4?o 71#
Det. /0-7--7--Tr Contractor "&6661 OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 fila a signed statement that he Is licensed pursuant to the provisions
' 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 ASPHALTSHINGLES 125
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).): WOOD SHAKES 11[:]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.
cions Code:The Contractors License Law does not apply to an owner of property who buildsor WOOD SHINGLES 11Improves 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-buiider will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of solo.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
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 Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
`71 am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PEWI FEE
WORKER'S COMPENSATION DECLARATION _
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Build!
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this -
permitIsissued. 'J r 'a seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
-the Labor Code,for the performance of the work for which this permit Is issued.My Worker's OCT co Total
Compensatlon Insurance carrlerrend Pollic)y number are:
Carrier r u�''y Policy No. 4/ ,,. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ., , V.�.
COMPENSATION INSURANCE N.C.❑ LI,.
Lr•n�f C V
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) fi
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 Cell- All rOOfS shall be inspected prior to any roofing material being
forma. q installed. If a roof is installed without first obtaining an
Dale�D�ZZ '` �Applicant C�� b _ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Ce icat.of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit sha10be doomed 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" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,costs and expenses which may in any way accrue against said City In consequence $IGNATU 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 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. 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 THE
POLICY U
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME: dp'«
APPLICANT'S SIGNATURE: �� D
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Rerool/wimvord