R-3977 PERMIT R_ 3977
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
10 NAME ago FIRE • 1O COVERING
O t AREA ►•J CLASS
ADDRESS D T L-!.l r EXISTING ROOF COVERING
PHONE ^�—� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CIT ais6 EXISTING
PHONE BUILT-UP ROOF
LICENS AS7KELS
S
NUMB$
WOOD
LICENSED CONTRACTORS DECLARATION '
1 hereby affirm that I am licensed under provisions of Chapter 9(common
cing with Section TOM) of Division 3 of the Business and Professions Code,
and my license is in full force and affect.
License Claes Lt..Number OTHER (SPECIFY)
Data Contractor
OVVNER�BUILDER DECLARATION
I hereby affirm that I .m eeempt from the Comr.ctor's License Law for PROPOSED
The following..non. (5«. '7031.6, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,.,
repair any str.Fluto, Prior to its issuance, also requires the applicant for such gUl LT-UP ROOF
parmit to Elle a signed statement that he is licensed pursuant to the provisions
of ma Co tractor's License Lew ICnePtar 9 (commencing with Section 70001
of Division 3 of the Business and Professions Code)or the
he Is exempt there ASPHALT SHINGLES
from end the basis for the alleged exemption. Any violation of Section
7031.6 by any eppl icant for a permit subjects the applicant to a civil penalty
of no[more Nat five hundred dollars($500).): WOOD SHAKES
❑ 1,as of the property.or my employees with wages es Nair sole
compensation,will do the work,and the structure is not intended o .tiered
for sale (Sec. 7044, Business end Professions Cotle', The Contractor',License S
Lew does not apply to an er of property who builds or improves thereon,
and who does such work himself o,through his own employees,provided that
such improvements are not intended or offered for sale. IL however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
p.rp.s..f sal..). PROVIDE I.C.B.O. REPORT NO.
❑ I. as r of the property, am exclusively contracting with licensed
contrac
for. to construct the project (Sec. 7044, Business and Professions
Code: Tn.Conb«tor'. License Law does not apply 10 an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves theroun, and who contracts for such projects with a
convactor(O licensed pursuant to the Contractor's License Law.
❑n 1 am exempt under Sac. ,B.&P.C.for his
rso
APPLICATION DATE VALUATION PERMIT FEE
Owner Date III PA
py
WORKERS'COMPENSATION DECLARATION r B® Building
I hereby affirm that I have a certificate of consent to self-insure,o 9
tifiute of Workers Compensation Insurance,or a certified copy[hereof(Sec. Seismic
3800,Lee
I] .C.1.
Policy No. Company �/I
Y U 1995 Z�W
C.rtiliad copy I.hereby furnished. Cot Certified copy I.filed wins the city inspection division 666
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
D ❑ r Clp IT AUTHORIZATION DATE
COMPENSATION completed
ON INSURANCE
I($100)or I naatl rapt be completed it the permit is for one hundred dol
Ian(51001 or Incl
I , Ih that in Na performance person
of any
work for which this permit is
sue. 1 anal) 'C employ any Lenon in env manna so es to become subj«t
to Na Workari Compensation Laws of California.
Data NT:AppIf.
NOTICE should
APPLICANT: o attar r eking this ons.1i site of Exemption,the
you Nowa b«oma st fortubj. i he mply eft h Such nroiOn ns or
a Ina
Labor epee, you must forthwith c.mmv with sncn Provisions or tma permit All roots shell be Inspected pNortoany roofing material being
shall be deemed revoked.
I certify the, I nay.r..d i.appncaIPn.fid stemet m.above Informs installed If a roof is installed without first obtaining an
tion is correct. I agree to g.Nmwy with all m city end county ordinances and inspection,I agree o remove all new materialsfor Inspection.
state laws meting to building construction, and hereby oulhor4a represem
tatives of this city to enter upon the abova�mentipnad property for inspection
Purports. \
(We) agree to gave, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,costs and expenses which may In any way accrue
againn sold City in consequence of the granting of this permit. SIGNATURE O PLI it
TV DATE
PRE-INSPECTION: PLYWOOD: IN-PRO ESS:
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 771E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERmtT AND INSPECf10N PHASE.
1. Prior to permit issuance, you must agree to comply with U.D.C. standards said manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and wrillen approval
from the building inspector. A final inspection said approval shall be obtained from the buildiug
Inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. 1r order to receive a rural,you must complete steps 1, 2,and 3.
l,) Prcirspecliou or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verificalior
b.) Spark arrestor inslallatiou
5. If plywood is installed,a plywood nail iuspcction is required.
G. If stay roof is applied without first oblaining str inspection, you will be required to remove all new
material down to the sheathing slid a building iuspeclor will inspect all sheathing at that lime.
WE UNDERSTAND 771E ABOVE POLICY ON REROOFING AND WILL COMPLY Wfrll TILE
POLICY
I IOMEO W NEMS NAME:
ADDRESS: O f t
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE: r
•
CITY OF CUPERTINO
BUILDING DEPARTMENT
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