R 5016 (2) PERMIT R_ 5 016
APPLICATION FOR CITY OF CUPERTINO. NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
19 -] {y !'rQ Q,Ce— RESIDENTIAL—)L COMMERCIAL OTHER
N 1Y,{ L HAZARDOUS FIRE AREA
NAME �66rn .r YES ❑ It yes—I understand that a Class
roof assembly is required.
,p NO ❑ Initial I.C.B.O.K
ADDRESS.!:,a m2 I 9XISTING.ROOF COVERINGQ
' PHONE �SJ '• �Q � / NUMBER OF EXISTING COVERINGS
CONTRA TOR'S / / J/`
f NAME S (;!&TO S f do 7 I n q TO BE REMOVED TO BE RETAINED
4 ADDRESS (JD 8o J I n n / -�a TYPE OF ROOF COVERING
CITY&ZIP r (�. r GVJ BYL
EXISTING
PHONE `/OR 3.5K_12 33 BUILT-UP ROOF ❑
LICENSE S ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I In affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business antl Professions Cotle,antl my license Is In full force and
affect.
C 39 y953� WOOD SHINGLES ❑
License Cleea Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from me Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 0l the /
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES \/Wpll
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).):
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 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.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) El
build or Improve for purpose of sale.).
❑I.as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.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 s
with a coniractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS / £y
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AU/� 7 1996
• perm la Issued. AUG
I have and wilt maintain Workers Compensation Insurance,as required by Section 3700 of �,Ieo Seismic
the or Cotle,for the performance of the work for which this permit is Issued.My Worker's 7.
CompenaenIn uran carrier and Policy number are: / GII UI- uut-rrTtIti TotalJa
r Carrier Policy No. •// �� PERMIT A THORIZATION DATE
CERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thio section need not be completed If the permit Is for one hundred dollars($100)100)or leas.) �V[
I certify that In the performance of the work for which this permit is laeuetl,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Lowe of Can. All roofs she be inspected prior to any roofing material being
forma. installed. It 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
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I certity 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 cc rings to be class"C"or better.
hereby purpose representatives of this city to enter upon the above-mentioned property for In-
hereby
purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
• lud,mento,costa and expenses which mey In any way accrue agalnst Bold City In consequence
of the granting of this permit. SIGNATURE OFAPPLICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
• 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.
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: /C D BB/wS
ADDRESS:.
REROOFING COMPANYNAME: GdS ygf�t /GbG.'G
APPLICANT'S SIGNATURE:
CITY OF OF CUPERTINO
BUILDING DEPARTMENT
• Rerooftwinword
MY OF CUPERTINO
BUILDING DMSION 408-777-3228
RE-ROOF TEAR OFF POLICY ,
1. You must schedule an inspection for the tear off the day before the date you wish the inspection to be
made. The procedure is to call the Building Division(777-3228)between the hours of 12:30 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 been
replaced, THEN YOU MUST CALL THE CITY BUILDING DMSION, An inspector will be
notified that the roof is ready, and he will respond to do the.inspection as soon as his schedule will
allow. There are special 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, THERE WILL •
BE A RE-INSPECTION FEE OF 569.00 CHARGED, WHICH MUST BE PAID BEFORE
ANOTHER INSPECTION IS MADE.
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reroof/winword