R-41684b
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APPLICATION FOR
REROOF PERMIT
CITY OF CUPERTINO
INSPECTION DIVISION
(408)252-4505 EXT. 228
OWNER'S //{,'/�
NAME i ii%, /C. Y'�s/,(/S/, ///�C�//
ADDRESS 1`1`16 /' Q1 z� '4 v 1/` KI fi 0 �
NAME
ADDRESS //i/�6 Y
CITY & 21P cp
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PHONE
LICENSE .�'''��j _-77
L I LENSED CONTRACTORS DECLARATION
1 herby affirm that I em licensed under provisions of Chapter 9 (common
eing with Section 7000) .1 Division 3 of the Business and Professions Code,
nd my license i. In lull roma and effect.
License Close- Lic. Number
Data Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for
the following reason. (Sec. 7031.5, Business and Professions Coda: Any city
or county which requires a permit to construct, alter, Improve, d.molish,cr
repair any structure. prior to in is also ediiinis th. applicant for such
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contraclor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda) or that he is exempt there
from and the basis tot the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that live hundred dollars ($500).):
❑ I, as owner of the property, or my employee. with wages as their Sole
compensation, will do the work, and the structure is not intended o offered
lot tele (Sec. 7044, Business and Professions Code: The Contractor's License
Law do« not apply toe owner of property who builds or improves thereon,
and who doe. Such work an
or through his own amployaes, provided that
such improvements are not intended or offered for sale. If, however, the
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
pulp..• 01 sale.).
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Coda: Tho Contractor's License Law does not apply to on owner of property
who builds or improves theroun, and who contracts for such projects with a
conttacto,(d licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sac. ,B.&P,C. for this
limn
Owner Data
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to salt insure, or a car
tifiC.* of Workers' Compensation Insurance, or acertified Copy thereof (Sec.
3800, Lab. C.).
Policy No. Company
BCertified copy is thereby furnished.
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(Thi. .action need not be completed if the permit is lot one hundred doL
lar. ($
100) or lesa.l
I Corti that in the performance of the work for which this permit is
issued. I shell not employ any person in any manner so as to become subject
to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: 11, after making this Cerlificate of Exemption,
you should became subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with Such provisions or this permit
shall be deemed revoked.
Icertify that I have road this application and stets that the above informs
tion is correct. I agree to comply with .II city and county ordinances and
.let. laws relating to building construction, and hereby auth,rite reitesem
btives of this city to anter upon the above mentioned property for inspection
purposes.
(We) spree t. save, indemnify and keep harmless the City of Cupertino
.,...atliabilities, judgments, Costs and expenses which may in any way accrue
.win., said City in consequence of the granting of this vermil.
NUMB R R- 41G8
PERMIT EXPIRATION
PERMIT EXPIRES W WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING USE
COMMERCIAL OTHER_
ROOF
COVERING
CLASS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
REMOVED
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY) P A
PROVIDE I.C.B.O. REPORT NNAY 25 1995
PROVIDE MFGR. INSTALLftTJ9I6SIUSFLr! Iry!
FEE
S U0 0 Seismic So
Total $7 S'D
PRE-INSPECTION: I PLYWOOD:
INSP. DATE INSP. DATE
All roofs shall be inspected prior to any roofing material being
installed If a roof is Installed without first obtaining an
inspe fon, I agree to remove all new rialsforinspa - n
7.
OF APPLICANT_/ T
JIN-PROGRESS:
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
SUBIECI': REROOFING POLICY FOR THE- CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PRASE.
-"'1. Prior to permit issuance, you nast agree to courply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied widnout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector wlneln [lie reroofing is completed. ;
3. All types of roof shall be inspected prior to any roof being installed.
d, In order to receive a final, you uasl connplele steps 1, 2, and 3.
l,) Preiuspeclion or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
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5. If plywood is installed, a plywood nail inspection is required.
G. If any roof is applied Without first obtaining an inspection, you will belrcquired to remove all new
material down to the shciWing and a building inspector will inspect 311 sheathing at Wal lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COrvIPLY WITH THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
Rerool7uinnord
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