R 4696 (2) PERMIT R_ 4 6 9 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
' REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
NE S ' HAZARDOUS FIRE AREA
NAME / I/�Jf7� YES ❑ If yes-roof as embly is
Wquiredd that Class
roof assembly is requiretl.
s��� � J NO Initial LC.8.0.#
, �Q WQ/�((�� C�C� EXISTING ROOF COVERING
PHONE d /(42 NUMBER OF EXISTING COVERINGS
CONTRAC R'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �� OSCOVERING
CITY&ZI,P
��� -
PHONE ���D b BUILT-UP ROOF ❑
LICENSE ❑ f
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter Il(commencing with Section WOOD SHAKES C
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 O
Date ^q Comramor OTHER(SPECIFY) ❑
OWNER-Bt ft'DFR CrECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the following r t to V
(Sec.70315,Business and Profedemolish,
or rep Cade: Any city or county which requires also a permit to /�^µ1��� 4 199 ❑
constructalter,Improve,to file 81mrepairanystructure.priorto Its Issuance,alsorequiresthe BUILTU IR"in�il L
of the o tr such permit a file a signetl statement that g with
Sectio pursuant to the Provisions �U
of the ss and Contractors License Law(Chapter h(commencing with om and 70001 of for the 3 of the rl•,
Business and Professions f Cade)or that he Is exempt therefrom and the belle for the applicant
to
ASPHALT SHINGLE$ ❑
exemption.Any ltyofolt more then
703 1.5 any s($50applicant for e permit subjects the applicant to - -u ffNQ
e civil penalty of not more then five y employees
m o dollyeesre with
wage
❑tee owner sthctureI not ty,or
tended oyeffered wages as their Bole compensation,sandPnfes- WOOD SHAKES
the work,and the structure is not Intended or s not for eels n ow er of property
and Plds or
improves thereon,
The Contractor's License Lew does elft apply to an owner of property who provided
t or WOOD SHINGLES
Improves thereon,end who tloes such work himself or through his own employees,Improvement etl that ❑
suchImprovementswithin
on eyeere not or owner-builder
for leer.It however,the en of pr vi Improvement
Is not bull or
prove for pucompletion,pose
sthe owner-bulltlar will have the burden lft proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracling with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
p 1 am exempt under Sec. ,S&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: -
[3 _/�`
1 have and will maintain a Certificate of Consent to solbinsure for Worker's Compensation, // /� D / Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this ( ` Sp
permit Is Issuetl. Seismic
1 have and will maintain Workers 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
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO o
(This section need not be completed II the permit Is for one hundred dollars($100)00)or IaesJ s.•�
I certify that In the performance of the work for which this permit Is issued.I shall not employ
any person In any manner so as to become subject to In Workers'Compensation Laws of call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date / YV Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TOAPPLICANT. If,after make Is Certificate of Exemption,you sh become Applicant understands and will cora p
subject to the Workers'Compensation provisions of the Labor Code,you must for ifth comply PP ply 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.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof rings to be of S"C"Or better.
hereby authorize representatives of this city to enter upon the above-mehiioned property for in.
spection purposes.
(Wel agree to save,Indemnify antl keep harmless the City of Cupertino against Ilabllltlas,
judgments,costs and expenses which may In any way accrue against said Cit,In conaapusnce
of the granting of this permit SIGNATURE OF APPLICANT DAT
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:
ADDRESS:
REROOFING COMPANY NAME: O /V
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword