R 4865 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4865
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN GAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING UIADDRESS 1
I q 1rp5 `,fJ OU� 1,k3s , RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\� \Q f YES E] If yes—I understand that a Class A
NAME_ l.. �1 NO roof assembly Is required,Initial
I.C.B.O.#
ADDRESS ?J Sy l k')C\J\�O\ - EXISTING ROOF COVERING
PHONE d S — I L—tNUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
r�S r N ` TO BE REMOVED TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF COVERING
CITY&ziP S SS
Q I EXISTING
C
PHONE - 1� 1 — ` 0� BUILT-UP ROOF ❑
B
NUMER ICEN ASPHALT SHINGLES
LED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in lull torte and
sneer WOOD SHINGLES
License Cleve _ Lie.Number az Z)r ,
Q aCl-tet(0 A Af\ (1,ni r �\A OTHER(SPECIFY) cf+ / l
Data Contractor RA ON J `�
OWNER-BUILDER DECLARATION PROPOSED g'`
hereby affirm that am exempt from the Contractor's License Lew for the following reason. `D
(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 9(commencing with Section 7000)of Division 3 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 applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compenestlon,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profits.
sluns Code:The Contractors License Law does nor apply to an owner of property who builds or WOOD SHINGLES
Improvise 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 sold within one year of completion,the owner-buoldor 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 Coda:The Contractor's License Law 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec, ,B&P.C.for this reason
Owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby aHlrm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Bui ldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit is Issued.andSeismic a70
❑ have and will the performance
Workers Compensation which this as requiredsu Section 3700 s q p
the Labor Code,for the performance of the work for which this permit le issued.My Wo re i� Q 5 ��
t000-
Comports if non a carrier and Policy number ar Total
Carrier lic,No. ER' IT T.HORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[
(This section need not be completed It the permit Is for one hundred dollars($100)or lase.)
,111, Ur V�
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workera Compensation Laws of Call. All roofs shall be inspected 17or to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provision.of the Labor Code,you must forthwith comply pP p y p
with such provisions or this permit sheli deemed revoked, source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
$(action purposes. \- O O
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, ✓ .-�
jutlgme' costa and expenses which may in any way accrue against said City in consequence
ofthegrennngdtthispermit. SIGNATURE Ull-APPLICW DATE
PRE-INSPECTION: PLYWOOD: IN-PROGR S:
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 DEPARTNIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.H.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.
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:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE: �� R r ��' csD --cltlr
CITY OF CUPERTINO
BUILDING DEPARTMENT
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