R-4105Lel
APPLICATION FOR
REROOF PERMIT
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 252-4505 EXT. 228
OWNER'S
HAZARDOUS
NAME FIRE
Ao�A
ADDRESS f�
NAME•^y' 6Q*,- /xx
ADDRESS
CITY & ZIP
PHONE
LICENSE
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commep-
clop wiso Section )000) of Division 3 of the Business and Professions Code,
and my license is in full farce and effect.
Licari..Clap Li.. Number
Date Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that Iam exempt from the Contractors License Law for
the following reeson. (Sec. 7031.5, Business and Professions Code: Any city
rcounty which requires a permit to construct. alar, improve. demolish,or
requiresepair any strucm to, prior to its isalso requires the applicant for such
permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 70001
of Division 3 of the Business and Professions Code) or that he is exempt there
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for s permit subjects the applicant to a civil penalty
of not mora met five hundred dollars ($500).):
❑ 1, 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 sela (Sec. 7044, Business and Professions Code: The Contractor's License
Lew does not apply t0 an owner of property luno build, or improves thereon,
and Who does such work himself or through his own employees, provided that
such improvements are not intended or offered for osis. 11, however, the
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he dict not build or improve for
purposeo1 sale.).
❑ I. as owner o1 the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contrac for's License Low does not apply to an owner of property
who builds or improves thereon, and who contracts for such projects with a
conlectorls) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B. .. I leer this
Owner Date
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a cerUfcate o1 consent to self insure, or a car
tific.te of Workers' Compensation Insurance, or a certified copy thereof (Sec.
3800, Lab. C.).
Policy No. Company
8 Certified copy is hereby furnished.
COl of ied copy is filed with the city inspection division,
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. ❑
(This section need not be completed If the permit is for one hundred dol
I... (3 100) or less.)
I unify that in the performance of me work for which this permit is
seed, I shall not employ any person in any manner s0 as to become subjest
to the Workeri Compensation Laws o1 California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Cartilicate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Code. you must forthwith comply with such provisions or this permit
.hall be deemed revoked.
I certify that I have read this application and state that the above informs.
tion is correct. I agree to comply with all city and county ordinances and
.tato lows relating to building construction, and hereby authorize repressor
tativas of this city to anter upon the above mentioned property for inspection
purposes.
(WO agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may In on, way accrw
.winst said City in consequence of the granting of this Permit.
NUMB R R' 4105
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING USE
rnULACIMPI A I
ING A
NUMBER OF EXISTING COVERINGS t
Tn NF PPTAIMPn O
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
PPLICATION DATE VALUATION PERMIT FE
fill
®® Building soof 10
F�U Seismic
6/1111 Total
I -'PERMIT AUTHORIZATION 1 DATE I
All roofs shall be Inspected prior to any roofing materiel being
Installed If a roof is installed without first obtaining an
inspectioq'I for fiVwea ewm err Isf rinspection.
��. %�
IGNATURE 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
0
11
•
SUB1ECf: REROOFING POLICY FOR TILL• CI'IY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comiply wills U.B.C. standards and mainufaclarers spec's
on reroofing.
2. New roof coverings shall not be applied willnout first obtaining al inspection and written approval
From the building inspector. A final inspection and approval shall be obtained from the building
inspector winen the reroofing is comple(ed.
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.
I,) Preinspeclion or tear off approval.
2.) In progress inspection npproval.
3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
G. Ir any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the slicatlning and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
I oaf I ��-
REROOFING COMPANY NAME: — —
APPLICANTS SIGNATURE: �-
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rewol7wh void