R-4700 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4 7
REROOF PERMIT )sl' PECTION DIVISION _ PERMIT EXPIRATION
_ } (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
l6�
avkI?:, /^C iiRESIDENTIAL COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
NAME y v L MD'i l�Iy LCI VES ❑ If of assembly s rengquiredt. Class A
(/' r NO Initial I.C.B.O.q
ADDRESS 85- 1 r 'r! ����C r' EXISTING ROOF COVERING .
PHONE
NUMBER OF EXISTING COVERINGS /
CONTRATCTOR'S ,-j r
e.: / 01 m O TO BE REMOVED TO BE RETAINED
NAME & a �r�( (!!!
ADDRESS
CITY&ZIP ZS'� 0 �7�rx`c,JHAQ e-V TYPE OF ROOF COVERING
4 ORe EXISTING
PHONE T o �S7 BUILT-UP ROOF ❑
LICENSE
NUMBER CS/ C9 O ASPHALT SHINGLES ElO /
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Lr JY
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
erect. ln•_ FWOOD SHINGLES El Clas ` Lic.Number � �J'�
Date �� Contractor(07,1517 !iiif A-0. OTHER(SPECIFY) L;Z
OWNER-BUILDER DECLARATION PROPOSED
I 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 OV 14 1 x 5
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions n
• of the Contractor's License Lew(Chapter 9(commencing with Section]000)of Division 3 of the C)It.Uh'
y
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES`. CN B((J
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(8500).):
C]1,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.
sions Code:The Contractor's License Law does not apply to an owner property who builds or WOOD SHINGLES
Improves
thereon,end who does such work himself or through his own employees,provided that El
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 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 Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATIONtDATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby affirm under penally of perjury one of the Ito seling declsure,for
Wo
I have and will maintain a Certificate of Consent to sell-fnsure for Worker's Compensation, 1110 r/ 1 A � 5 Building
as mit Is for by Section 3700 of the Labor Code,for the performance of the work for which this �V 0 Y J
permit isveanIssued. Seismic
❑I have end will maintain Worker's Compensation Insurance,as required by Settlors 3700 of T-v
the Labor Code,for the pe .mance of the work for which th� erml iyGSYN�A�fyork� C(1 ` Uf LVi tr{I Ing .LkC
Total
Comp tion In nc .tief.r end Policy number ere: l/V��"(�.�
.,net— Policy No. PERMITAUTHORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NO.[
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
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 Workers'Compensation Laws of Cali- All roofs shall be inspeC ed prior to any tboting mal rial being
fornia. 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,after making this Certificate of Exemption,you Should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply Y P
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
to comply with all city and county ordinances and state laws relating to building construction,end All r of coverings t be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,costs and expenses which may In any we,accrue against said City In consequence
of the granting of this permit. NATURE APPLICANT DATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
f '
•
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT 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.
a.) Operable smoke detector verification
• b.) ' Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
G. 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 r r'
HOMEOWNERS NAME: !36,4 K2
ADDRESS:
REROOFING COMPANY NA : OOW
ME
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Reroof/winword
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