R 4851 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4851
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
RESIDENTIA-;OCCOMMERCIAL OTHER
OWNER'S I l�/)/� . l �" L ,� I HAZARDOUS FIRE AREA
NAME �/jfl / ,V V ,L NSC VES roof assembly s�equirend atBa Class A
Vi J NOfriInitial I.C.B.O.#
ADDRESS gV r D iia 14 n s cn_ /L O EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
y CONTRACTOR'S �} � 1
l�e QQtI » TO BE REMOVED `�TO BE RETAINED
NAME
ADDRESS '7(`_�� ll70a TYPE OF ROOF COVERING
CITY&ZIP— ^� EXISTING
PHONE— 2Z y/ � J-2,0 B -UP ROOF ❑
LICENSE
NUMBER ASPHALTS LES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. ^ K 2 WOOD SHING
License Chess� Lic.Number ( a+ ` 22
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED T r
hereby affirm that am exempt from the e: Any
License Lew for the following reason.
(Sec.7031.5,alter,BusinessImprove entl Profeolish,or rep Cotle: Any city or county which requires a parmlt to
constructapplicant forsu Improve,to file demolish, statement
anystructure,n is licenseor to Issuance,pursuant
alsorequiresprovisions
the BUILT-UP ROOF
applicant for such permit to Ills a signed efelemenl that he le licensed pursuant to the provislona
of the Contractor's License Lew(Chapter 0(commencing with Section 7000)of Division 3 of the
Business and Professions Cotle)or that he le exempt therefrom and the basis for the alleged ASPHALT SHIN
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to I l
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 on,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
alone 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) ❑
not build or Improve for purpose of sate.).
❑I,as owner of the property,em 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 contractor(S)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
E]1 am exempt under Sec, ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PER T FEE
I hereby affirm under penalty of perjury one of the following declaration: S o
Y ❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, ��� Building
as provided for by Section 3700 of the Labor Code,for the pedormanco of the work for which this 15
permit is issued. 199{ _M Seismic
❑I have and will the performance
Workers f the work
for Insurance,as required by d.My
Worker's's ss�� W
'Co Leber Code,for the performance of the work for which this permit Is Issued.My Worker's
Compenaetlon Insurance carrier and Policy number are: �'I r LJI' (r�i'tf(I jiff.. Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Title section need not be completed If the permit Is for one hundred dollars($100) r IaesJ
1 certify that In the performance of the work for which this permit Is Issued,I shell t employ
any person In any manner so as to become sub' t to the Workers' formation L a n call- All root.^•shall be insp rior to any roofi mlteri I beiNg
forum. installed. If a roof is installed without first obtair ing an
afel�-9L Applicant inspection,I agree to remove all new materials for inspection.
10 subject to the WoPkersCCompeIANT fnsatlo`n provisions ofthe °cos g�m�;°foinrllin�omolY Applicant understands and will comply with all non point
with such provisions or this permit shafte deemed ravo ad, 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 state laws reining 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 me City of Cupertino against IIa1o011les, /V
judgments,costa and expenses which may In any way accrue against said City in consequence
of the granting of this permit. S R APP CANT DATE
PRE-INSPECTION: PLYWOOD: IN-PRO RESS:
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.H.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:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword