R 6212 PERMIT R_ 6 212
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT IRES IF WORK IS NOT STARTED
WITHIN 180PDAYS OF PERMIT SSUANCE OR
180 DAYS FROM 41ST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIl COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME !�' roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE
`J///'/ —3 yz NUMBER OF EXISTING COVERINGS /
CONTRACTO
TO BE REMOVED , TO BE RETAINED
NAME_ "��
ADDRESS SO Ly� O
CITV&/ZIP EXISTING Z/Z
PHON��SSJ� BUILT-UP ROOF /❑gJ"
LICENSE L f�-��OU ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of DwIslon 3 of the Business and Professions Code,and my license Is In lull force and
effect.
9`2- 7 WOOD SHINGLES ❑
License Claes � `3 Lie.Number �U
Date �� / Contractor OTHER(SPECIFY) ❑
OWNER-BUILDERDECIARATION PROPOSED
hereby affirm 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 a(commencing with Section 7000)of Division 3 of the
• Business and Professions Coda)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 applicant to
a civil penalty of not more than five hundred dollars(85(30).):
01,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 Profes.
Bions 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.ll,however,the building or Improvement .7
Is mid within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ 0`z
not build or improve for purpose of sale.).
❑f,as owner of the property,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 bulltls 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 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE - VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: r'
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, CFO Building Q U
as provided for by Section 3700 o1 the Labor Coda,for the performance of the work for which this y p / g
p r t la Metl. - �/ /a/` �(�O Seismic �O
ave antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
th bor Coda,for the performance of the work for which this permit is Issued.My Workers `O
Compansaban Inau nca carrler and Policy number are: ` Total •J
Carrier �1 �'^� PolicyNo.SW ? "/Z� PERMIT AUTHORIZATION 9ATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE WC // y
(This section nnot be completed If the permit le for one hundred dollere($100)0)9 or less.)
' I certify that In the ponormen<e of the work for which this permit Is Issued,I Snell net employ
any person in any manner so as to become subject to the Workers'Compensation Laws of call. All roots shall be inspected prior to any,rooting material being
fornix' installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject 2 the WE TO mke�eCcompensaiion provisionls ofetheficate of Laborr Code,yolu must forthwith 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.I agree ,,,,,,//////j����j��-��-
tocomplywithallcityandountyordinancesandstatelawsrelatingtobuildingconstruction,and All roof Coverings f ba Clas or better. .
hereby authorize representatives of this city to enter upon the above-mentioned property Mr in, A J�
ap ction(We)purposes. s! <q
(We)agree to save,expenses
and keep harmless the City ai Cupertino against liabilities, y[l/�
of the gran,costs entl permit, a which may In any way accrue against said City in consequence
of me granting o1 this permit. SIGNATURE APPLICANT" DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS: -
INSP. DATE INSP. DATEINSP. 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 PE21v(1T 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.
• b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
b. 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 COiv1PLY WITH THE
POLICY
HOb1EOWNERS NAME:
ADDRESS:: :
REROOFING COMPANY NAME:
APPLICPuNTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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