R-4918 (2) PERMIT R_ 4 918
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRESIFWORK ISNOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z'� 2- I Za_53 J RESIDENTIALjL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
^ 170 G} Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS lr�
CONTRACTOR'S
' TO BE REMOVED�TO BE RETAINED
NAME
ADDRESS cj 3/� Q _o TYPE OF ROOF COVERING
CITY&ZIP cam.
' / EXISTING
PHONE `y�Q$7 � � ��/Q L2-- BUILT-UP ROOFLICENS
NUMBER / Z2, ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
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 lull force and
effect. C 3 WOOD SHINGLES
License CIa58 Lia IN bar 4 t Z' ❑
��� rj (A OTHER(SPECIFY)
Date�_ DBUILIDer
OW from th ILDER DECLARATION PROPOSED n
hereby Shim Bu that am exempt from the Contractors License Law for to requires
a re t to
Ca tl
(Sec.7031.5,Business and demolish,
or re Code: Any city or county which re,also a permit to
a licant,orsu alter,Improve,to file signed statpair eny ment that
prior colts)pursuant to
siha BUILT-UP ROOF 1'Ipp��
eppllcent for each permit to llleesigned statement that ha is licensed pursuant to the provisions JUN 1996
of the Contractor's License Lew(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 live hundred dollars($500),): GI Ir Ur- ryA'Cr11 INV
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES LJ
the work,and the structure Is not Intended or offered for sale(See.7044,Business and Profes.
sions Code: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-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 Contractors 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
;-' Owner yyORKER'SCOMPENSATION DECLARDate
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 self-Insure for Worker's Compensation, Bull ding 7,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is 159uetl. 7 .r Seismic
❑I neve and will themaintainrt Worker's Compensation the wokfor Insurance,as required by Section Worker's 0l / /G/. .Y JlJ-� /fir
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Workara J � ( /(O
Compens 11pn Ins ante c nipr and Policy number are: '.1 Total
Carrier 1 Policy No. W � ' -3 .,� PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPE ATIONINSURANCE NC.]
(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 ffffff���
any person In any manner so as to become subject to the Workers'Compensatio Lawn ai calf. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date �` � Applicari / r ` 0 inspection,I agree to remove all new materials for inspection.
NOT become
subject lothe OWorrkere Compensation o proafter ivisionis of theflcate of Laborr Code,yoiu 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 certify that I have read this application and Stale 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 coverings to 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 fabllitles,
oftcosts
expenses which may In any way accrue against said City In consequence
he granting of this permit. SIGNATURE O�ICANT DATE I-
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: 1
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE: I\f
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Reroof/winword