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OFFICE COPY
PERMIT R_ 4 5 0 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 ,
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S U^
HAZARDOUS FIRE AREA
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YES ❑ Ifyes that. Class
NAME C� V' +'
ro01 assembly is rand
s assemunderbly required.
NO ❑ Initial I.C.B.O. #
/ G�
EXISTING ROOF COVERING '
ADDRESS /�
NUMBER OF EXISTING COVERINGS
♦ ���"
3 — S-3
PHONE TlQ
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S S ji M^ Q
lr
NAAME
,. )�'
TYPE OF ROOF COVERING
ADDRESS -33 0 --:PhI -ta �
7
CITY & ZIP
EXISTING
/ 7� �`tSr
PHONE
BUILT-UP ROO� ❑ -
NUMBER Sl 30 4 / 113 5
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000)al Division 3 of the Business and Professions Code, and my license Is In full force and
effect. A
�j � � �
�/�
WOOD SHINGLES El
License Class "� Lia Numbs
/!_ 9 —'j 5-Con
OTHER (SPECIFY) ❑
Date tractor
OWNER-BUILDER DECLARATION
PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for ih wing reason.
(Sec. ]031.5, Business and Professions Code: Any city or county whl quires a permit to
construct, eller,improve,demolish, or repair any structure, prior to i uance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to Ills a signed statement that he Is II ad pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencin Section 7000) of Division 3 of the
Business and Professions Code) or that he is exam erefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation o1 Section 7031.5 by an plicant for a permit subjects the applicant to
e civil penalty of not more than five hundred ars ($500).):
❑ I, as owner of the property, or my Ioyees with wages as their sole compensation, will do
WOOD SHAKES
the work, and the structure Is not i ded or offered for sale (Sec. 7044, Business antl Proles.
-
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slons Code: The Contractor's nso Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
improves thereon, and wh as such work himself or through his own employees, provided that
such Improvements ar t intended or offered for sale. If, however, the building or Improvement
if
Is sold within one y of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑_,
not bulid or im a for purpose of sale.).
❑I, as or of the property, am exclusively contracting with licensed contractors to construct
the pro' (Sec. 7044, Business and Professions Cade: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
a o an owner of property who builds or improves thereon, and who contracts for such projects
a contractor(s) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. .B 8 P. C. for this reason
Owner Date
APPLICATION DATE ; EVALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
y
Building
I hereby affirm under penalty of perjury one of the following declaration:
1 have Certificate Consent to sell -Insure for Worker's Compensation,I'
❑ and will maintain a of
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
n
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permit is issued.
eve and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Code, for for this Is Issued. My Worker's
(�o '! • V V
CI I
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Seismic
the bor the performance of the work which permit
f 14,' V t. r'611 II41
Total
Compensation Insurance carrier p4 Policy number are:
-4-
PERMIT AUTHORIZATION
DATE
Carrier`RP.vIL.G��fL J7llA 'QYl1h��(p�cy No.�G96,022
CERTIFICATE OF EXEMPTION FAR WORKERS'
COMPENSATION INSURA CE N.C-0
(This section need not be completed if the permit is for one hundred dollars ($10 ) or lase.)
.\i
I certify that In the performance of the work for which this permit is Issue all not employ
any person In any manner so as to become subject to the Workers' C as lo n Laws of call-
II roofs shall be inspected prior to any roofing alerts being
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTecome
lloEtheOAPPLICANT: If, after makVlsions
cate of Exemption, uforthwitlhbcomply
Applicant understands and will comply with all non point
subject Worrkers'C mpensatlo oftheLabor Cotle, you must
with such provisions or this per ell be deemed revoked.
SOUfCe regulations.
certify that re a supplication and stele that the abovelnformation is Mrrect.I spree
to comply with all ci county ortlinances antl elate laws relating to bulldlnB construction,end
StO be ss"C"Or better.
hereby authoft resentatives of this city to enter upon the above-mentioned property for In-
spection p see.
/%v^7/r/y0OVefin
( gree to save, indemnity and keep harmless the City of Cupertino against liabilities,
✓t
encs, costs and expenses which may in any way accrue against Said City in consequence
SIGNATURE OF APPLICANT DTE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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OFFICE COPY
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SUBJECI': REROOFING POLICY FOR '111C• CI'T'Y OF CUPERTINO BUILDING DEPARTNIHNT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, YOU must agree to comply will, U.B.C. standards and mauuf cturc:s spec's
Oil reroofing.
2. New roof coverings shall not be applied tviliroul first obtaining all inspection and written approval
from ilia building inspector. A finml iaspcclian and approval shall be obtained from the building
inspector tvirea the rcreafing is completed.
3. All types or roar shall be inspected prior to ally roar being installed.
d. In order to receive a final, you must ceurpiete steps 1, 2, and 3.
l,) PreilIspecticil or tear off approval.
2.) In progress inspection approval.
3.) Final intspectio❑ approval.
aJ Operable smoke detector verificaliou
b.) Spark arrestor installation
1
5. Irplywaad is iustallcd, a plywuod nail iispcciian is required.
G. Ir any roar is applied without first obtaining an inspection, you Will be required to remove all uc•.v
utatc:ial dawn to the she,thing and a building inspector Will iuspr_t all sheathing at dial Lima
WE UNDERSTAND TILE A130VE POLICY ON REROOFING AND WILL COMPLY WITII TILE
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CI'IY OF CUPERTINO
BUILDING DEPARTMENT
Rercof/uimrord
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