R 4742 PERMIT
APPLICATION FOR CITY OF CUPEFr NUMBER R- 4742
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
I
W
" THIN 180 DAYS OF PERMIT ISSUANCE OR
WDANS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7 ry v tr O Y✓- h N.l RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes-I understand that a Class A
NAME • root assembly is required.
NO [ Initial I.C.B.O.K
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 2—
CONTRACTQ)R'S
NAME /�� Ldp I S TO BE REMOVED 4 � TO BE RETAINED
ADDRESS �f'1 ,6 (1 TYPE OF ROOF COVERING
CITY&ZIP YID u 1 `f C �r,o4 95561,
p EXISTING
PHONE ( — d' �•` �' BUILT-UP ROOF
LICENSE 35
NUMBER t�2 ASPHALT SHINGLES m.
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am 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.
r� 0 WOOD SHINGLES
Ucens JIaae ` 3 Uc.Number
Dale (/ Contractor L- r.� • / �i,�P� 0 � /`�THER(SPECIFY)
J— 191
OWNER-BUILDER DECLARATION PROPOSED Z/
I hereby affirm that am exempt from the e: Any
License Law for the fallowing mason. C
cons.7031.5,Business Improve and Professions one Cotla: Any city or county which requires a permit to
consapplicant
alter.Improve,demoto file signed statement
anystructure,Is licenor tose lseuance,oleos Provisions
the BUILT-UP ROOF ❑
applicant for such permit to flaw a signed r 9(commencing
nci he le licensed pursuant to the pro of the
of the Contractor's License Law(Chaplet h is exempt t ereh Section 7000)of (or the 3 of the
Businessptio and violation of Code)or that he le y applicant
therefrom end the baste for the applicant
to ASPHALT SHINGLES ❑
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than Ilve huntlretl tlollare($500).):
❑1,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 Proles.
sions Code:The Contracto(a License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his awn employees,provided that ❑
such Improvements are not Intended or offered for sale.It,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the properly,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 MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B&P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION PATE1 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
E]I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, y w BUlldln '
e as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this It qr.{
permit is Issued. N
❑1 have end will maintain Worker's Compensation Insurance,as required eco of, - v,/7 u QG7 SBISRIIC �► /►lJ
the Labor Cotle,for the performance of the work r which this pe t)rl / r�'s h L(/N�n 1 ` Total
4
Compensation Insurance cgrrler entl Poll numb e: 7 yffy L
Carrier 7y Q- + Policy No. PERMIT AUTHORI TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D t
(This section need not be completed If the permit Is for one hundred dollars(S100)or leas.) `
I certify that In the performance of the work for which this permit Is lesuetl,I Snell not employ
any person In any manner so as to become subject to the Workers'compennnuon Lawe of can- All roofs she be inspected pri0 to any roofing material being
forma' n installed. If a roof is installed without first obtaining an
Date m:2.q L Applicant . iLA'/' inspection,I agree to remove all new materials for inspection.
subject too the Workers'Compefnsatl n provisions of theflcate of Laborr Code,Exemption,
mustforthwith become
comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I cenlly that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction
,entl All of coverings to be class"C"or better. ^�
hereby authorize representatives of this city to anter upon the above-mentioned property for In- U) i /r Z 2 r7
hereby
purposes.
(We)agree to neva,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,tcoats and ewhich may In any way accrue against said City
ofthe
granting p
In consequence
ngof ante 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 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[tail 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
HOMEOWNERS NAME:
ADDRESS: znX
REROOFING COMPANY NAME: 2 ^
APPLICANT'S SIGNATURE: ,
CITY OF CUPERTINO
BUILDING DEPARTMENT
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