R-4630 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4630
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
74 Z / Q JC /iG' d RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME <'/ ` � YES ❑ II yes—I understand that a Class A
root assembly is required.
NO Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�r/� TO BE REMOVED TO BE RETAINED
NAMES,40`'l�( &� td 77 �l 4)O C1/1/1��
CADDRSSIT/&EZ P 6� Slid N M L v u RJ Q �S�VL Q`�p9�o TY E OF ROOF COVERING
EXISTING
PHONE O� 73�^ � BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 0�
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
affect WOOD SHINGLES ❑
License Class Lic.Number -
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 0l the LJ
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(8500).): WOOD SHAKES ❑
❑1,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 Protes.
alone Cotle:The ContraWOOD SHINGLES ctor's License Law does not apply to an owner of properly who builds or
Improves thereon,antl who does such work himself or through his own employees,provided that E]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 1e 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 conlractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
O 1 am exempt under Sac. .B&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, B fJ I �' Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (Q d(lf
permit is issued. OCT 12 I Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 I
the Labor Code,for the performance of the work for which this permit is issued.My Workers 995 Total
Compensation Insurance carrier and Policy number are: C(l,.r rL
Carrier Policy No. 'PERMIT/AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ��
(This section need not be completed if the permit is for one hundred dollars is less.)
I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person in any manor so as to become subject to the workers camp nsaun Laws m cab All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date/�� Applicant d'H inspection,I agree to remove all new materials for inspection.
OTlohOAPPLICANT: loyy should fb
subatrkersCmpensation provl nsoftheLborCode, oumonhMthomply Applicant understands and will comply with all non point
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.)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. s
hereby authorize representatives of this city to anter upon the above-mentioned property for In- AQ W
In-
spection purposes. /�•�Y �
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,casts and expenses which may in any way accrue against said City in consequence NATURE OF APPUCA DATE
of the granting of this permit.
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
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:
ADDRESS: 7 s- c—[ / Ltd A- J9
REROOFING COMPANY NAME:
47
APPLICANT'S SIGNATURE: r,.2�
CITY OF CUPERTINO
BUILDING DEPARTMENT
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