R-5629 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB R R- 5629
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
RESIDENTIAL COMMERCIAL OTHER
O E 'S� l V l r 1--,, HAZARDOUS FIRE AREA
N ME �o YES ❑ If yes–I understand that a Class A
roof assembly is required.
NO -❑ Initial
ADDRE (�� EXISTING ROOF COVERING
PHONE �'2— VLf NUMBER OF EXISTING COVERINGS
CONTRACTOR'S // 1
NAME ) ;coil Llrie'v Ilrq d�7 N TO BE REMOVED TO BE RETAINED
ADDRESS3,63-7
3 6 3- �SYIK/� �IYG PE OF ROOF COVERING
clTv s zIP J r--'� EXISTING
PHONE � -1p2 6 9 BUILT-UP ROOF ❑
LICENSE 2 ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. r�ff WOOD SHINGLES ❑
License Class ? Lic.Number
r L)
Data Contractor OTHER
OTHER(SPECIFY) / ❑
/
OW -BUILDER DEC ATION PROPOSED
hereby affirm that em exempt trainNEE the Contracts' IATIO Law for the following reason. y
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Q
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 P AD
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 r�[�
a civil penalty of not more than five hundred dollars($500).):
I] WOOD SHAKES ��eepy 1 1{�U Iv
I,as owner of the property,or my employees with wages as their sole compensation,will do MM
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 of property who builds or WOODSHINGLES t t+ HTINO
Improves thereon,and who does such work himself or through his own employees,provided that CI I Y uIr V
such Improvements are not Intended or offered for sale.If.however,the building or Improvement V
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 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 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
Fj I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's (�0/).�//p1
Compensation Insurance carrier and Policy number are: Tota
Carrier Policy No, PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' If
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars f il0 or ass
I certify that in the performance of the work for which this permit Is issued,I sh not employ
any person in any manner so as to become subjec he Workers'Comp sation we of Cali- All roofs shall be inspected prior to any roofing material bei
ng
forma. installed. If a roof is installed without first obtaining an
Date ` f 1 q� Applicant 4 inspection,I agree to remove all new materials for inspection.
subject to theICE OWorkersCC Comp ,after ensation n prolvisions ofthlelctilleLabor Code, u must forthwithcecome
omplyApplicant understands and WILLQjZply with all non point
with such provisions or this permit shalrbe deemed revoked. source regUjahODS.
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 overings to Class rb er.
hereby authorize representatives of this city to enter upon the above-mentioned property lar In.
spection purposes, �t J
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities.
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. AT OF PLICANT DATE
PRE-INSPECTION: PLYWOOD: IN- OGRESS:
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 BIJUDM DEPAa-171MENT
PRIOR TO ISSUANCE OF PER.NII T AND INSPECTION PHASE.
1. Prior to pe mit issuance, you mus agree to comoly with U.B.C. standards and manufacn rets spec's
r on re:co£mg.
Ne.v roof coverings shall not be at) w thous first obtaining all ins a obtained
and o Geo acproval
wT `from the building inspector. A final inspec on and approval shall be obtained from the buildins
inspector when the reroofing is compieted.
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,) P:einspectioa or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke de,.--.or verification
• b.) Spark arrestor installation
5. If plywocd is installed,a plvwocd nail inspection is required
6. If any roof is applied without first cbtaining an inspection, you will be required to remove all ne'.v
material down to the sheathing and a building inspector will insect all sheathing at that time.
E UNDERSTAND THE ABOVE POLICY ON REROOF NG AND WILL COMPLY WITH TsE
W
POLICY / r�
HOiviEOWNERS NAME:
Oo4 Y� Z�
ADDRESS:
REROOF u IG CObtPANY NAIY :
APPLICA`+TS SIGNATURE:
Cl i f OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winwdrd
CITY OF CUPERTNO
BUILDING DIVISION 403-77-3223
i-3223
RE-ROOF TEAR OFF POLICY
' L You must schedule an inspection for the tear off the day be—fore the date you wish the inspection to be
made. The proccdute is to call the Building Division(7777-3223)between the hours of 1230 and 4:00
P.m.for next day inspection_
2. When the roof is torn off, the nails removed or driven in and all of the dry rotted wood has beta
replaces, TION YOU MUST CALL THE CITY BUILDING DMSION. An instector will be
notified that the roof is readv, and he will respond to do the inspection as soon as his schedule will
allow. There are spec—'al hours for this service between 8:00 am. and 11:00 am., and between 1:00
and 3:00 p.m
IF YOU CALL FOR THE TEAR-OFF INSPECTION AND THE JOB IS NOT READY, Th-aRE WILL
• BE A RE-INSPECTION FEE OF $69.00 MARGED, WHICH MUST BE PAID BEFORE
ANOTHER INSPECTION IS MADE.
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