R-4599 (2) =1
APPLICATION FOR CITY OF CUPERTINO
NUMB R R- 45 9 9
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
OWNER' HAZARDOUS FIRE AREA
9 1 YES ❑ It yes—I understand that a Class A
i`
NAME roof assembly is required.
NO--FLInitial I.C.B.O.#
ADDRESS O /O \` d 'OeL p,,V EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT^ —
NAME �1�-`Fl/ TO BE REMOVED TO BE RETAINED
ADDRESS7� S•-' ECOVERING
CITY&ZIP �B✓S /—/7 �R.
EXISTING
PHONE ".1-3 "r "I 1 BUILT-UP ROOF ❑
LICENSE Gr O 5' ASPHALT SHINGLES
NUMBER a ❑
LICENSED CONTRACTORS DECLARATION ��..��cc--wwww
I hereby affirm that I em 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 full force and
afleet. WOOD SHINGLES
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
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 ❑
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($500).): WOOD SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Cade:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of said.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S&P.C.Mr this reason
Owner Date APPLICATION DATE . - VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: "a Q ID6
r7 have and will maintain a Certificate of Consent to self-insure for Workor's Compensation, �p Building V
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. 1679
�� Seismic
�
❑I naveve and will maintain Workers Compensation Insurance.as required by Section 3700 of�1). A
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's may- O Total
Compensation Insurance carrier and Policy number are: Go�,LV
Carrier Policy No. PEFIMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($ )or .)
I certify that in the performance of the work for which this permit Is Issued,I s Pit employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any r ofing rilatterial being
rdr^Ia. Q ✓^ installed. If a roof is installed without first obtaining an
ate " Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject to the wmyerecomponseion provisions of theL bort Code,you mustuforthwitthshould ocomply Applicant understands and will comply with all non point
with such provisions or this permit ahafte deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.)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.
herby authorize representatives of this city to enter upon the above-mentioned property for In.
spectre)purposes. _\\ _� C w\\C O
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, (j�Q� �J O J
judgments,costs and expenses which may In any way accrue against said City In consequenceS ATURE OF APPLICANT DAT
• of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DAT 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.
.1 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: Lo to C"A I��
ADDRESS: 103clo
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Rcroof/wimvord
lw
Cir-" or :�
Cuperth1 o L
SMOKE DETECTOR CERTIFICATE OE COMPLIANCE
I understand and comply with Section 1210-A of the Uniform Building Code.
Section 1210-A requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed; mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used for sleeping
• purposes. If existing smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE: G
DATE: '
winword/smkdet ,
•
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