R-4572 APPLICATION FOR CITY OF CUPERTINO
PERMIT R- 4572:1
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-',3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
„ 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING AADDDRESSSI I na
_20q v 5 �'e 4I Jr4aQL
_ r RESIDENTIAl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
^) 1VES ❑ If yes—I understand that a Class A
NAME Y V'� I / C / root assembly is required.
�c� NO Initial I.C.B.O.If
ADDRESSP25 Pe oT-')t�e l EXISTING ROOF COVERING
PHONE
L4 4 , Z 3 NUMBER OF EXISTING COVERINGS 1
CONTRAC�TTOR'$
NAME F Z G TO BE REMOVED TO BE RETAINED
ADDRESS ' 1 _^v TY E OF ROOF COVERING
CITY&ZIP t��'c.Y t
^7 EXISTING
PHONE GBUILT-UP ROOF ❑
LICENSE
NUMBER W ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect' Iff WOOD SHINGLES
License Class S,C' Ue a,
Data��I 1� Conirenor157r Z r� ' �^--'� OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby aOlrm that I am exempt from the Contractor's 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 file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)or Diva 1013
of the
Business and Professions Code)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 app Ilcant to
a civil penalty of not more than five hundred dollars($500).):
SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
scone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves 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 cold 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 property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. .B 5 P.C.for this reason
Owner Date APPLICATION DATE VALUATION P 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 sell-insure for Worker's Compensation, BUI g
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this SEP
-1 1 ��
per It is lssuetl. Elle 5 SBIs IC
hive and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Le or Code
,for the performs a of the work for which this permit Is leeuetl.My Worker's /N/�1O (t
Compensation Insurance c "Itis a Polity number are: '�I���- CIIY Ur t,UrEH i I Vv ` O Total
Carrier S— POIIcyNO. PERMITAUTH TI % ATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed If the permit Is for one hundred dollars($100)or less I
I certify that In the performance 01 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 Cali. All roofs shall be inspected prior to Any roofing material being
lornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the a WorkersTO ' If,after
provisions of thecate Labor Code,Exemption,
Iu mustuforthwith decome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed 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 rgW s C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In- ,1
sprite)purposes. , 4_11r�
agree
(We)agree to save,expenses
and keep harmless way the City ai Cupertino against liabilities,
IudRments.gran coats and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
of t e granting of rola 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: 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. ' 1.
1. 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
HOMEOWNERS NAME:
ADDRESS: zoq 4.5 Pe e�'1 J 1,
REROOFING COMPANY NAME: C0^
APPLICANT'S SIGNATURE: 1
CITY OF CUPERTINO
BUILDING DEPARTMENT
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