R-4513 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4 513
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
1w DAYS FROM LAST CALLED INSPECTION.
Y
1A)"
(�}��
/ Sr� �%
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes-I understand That a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS �, ! // — EXISTING ROOF COVERING
PHONE "'�'� (O �/0 Z Z-- NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S '
TO BE REMOVED �TO BE RETAINED
NAME
ADDRESS !40 � TYPE OF ROOF COVERING
CITY&ZIP O/6��ry��n a+� V EXISTING
PHONE `y /j�`� -G4/5� BUILT-UP ROOF ❑
LICENSE
UMBER 6 G
N6 6 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am Ilcensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect. / L WOOD SHINGLES El ��Nff
License ClassC25 (�LIc.Num `v 6
(j OTHER(SPECIFY)"'
Dale— • Contract }J`�✓'1/U�_�
OWNER-BUILDER Cs License
PROPOSED ��✓ �`
1 hereby affirm that am exempt from the e: Any
License Law for the following permit
t.
(Sec.7031.5.Business and Professions Code: Any dty or county which requires requires permit to
constapplic lit,or su Improve,demelish,ora sign repaa eny mentrthat I,prior to lis 1pursuee,also0provtheIon6 BUILT UP ROOF ❑
applicant for such permit to lila a signed r 9(co ant that he Is licensedSection
pursuant to the prove the
' of the Contractor's License Lew(Chapter a(commencing with Section]000)of Division 3 0l the '
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES DID
exemption.Any violation of Section]031.5 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.
slons 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-Wilder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct 30'5the project(Sec.7044,Business and Professions Code:The Contractor's 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR^INSTALLATION SPECS.
❑1 am exempt under Sec. ,B It P.C.for this reason d
Owner Data APPLICATION DAT TION PERMIT FEE
WORKER'S COMPENSATION DECLARATION i
I hereby eHirm under penalty of perjury one of the following declaration: 11
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, (( .\O
as provided for by Section 3700 of the Labor Code,for the performance of the Werk for which this �p�/ �UYI%1{f1N Building
permit Is �L 1l.J'�r 3�Z Seismic
have and will the performance
Workers f the work
for Insurance,as required by Sectiod.My
Worker's's 1
C-thbor Code,for the performance of the work r a which ibb permit Is Issued.My Worker's Total
Compensation Insurance carrier an tl Policy number are: p
Carder l�/�'s-ss.�'s'� & Policy NJWC'USQe:q/ PERMIT AUTHORIZATI DATE
CERTIFlrAA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑
(This section need not be completed II the permit b for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Celb All roofs shall be inspected prior to any roofing mAleriaT being
forne installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,after making this Certificate of Exemption,you should become Applicant understands and WIII comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such previsions or this permit shalQbe deemed revoked. Source regulations.
I certify that I have read this appllcatlon and state 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 covert Stob class�'C"or better.
hereby authorise representatives of this city to anter upon the above-mentioned property for Im �'^N1���
herebspectiy
purposes.
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence ��
of the granting of this permit. SI NATU OFSI NATU OF APPLICANT Y EE
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: ILEROOFtNG POLICY POR TIlE Cl'I'Y OF CUPERTINO BUILDING DEPARTv1EN
PRIOR TO ISSUANCE OF PERNUT AND INSPEC 11ON PHASE.
1. Prior to perruit issuance, you "rus( agree to comply with U.B.C. standards and nlanufclurcrs spcc's
Oil reraafing.
2. New roof coverings shall not be applied wiUnout first obtaining all inspection and written approval
Goin the building inspector. A final inspection and approval shall be obtained from Ifne building
inspector when the reroofing is complcicd.
3. All types of roof shall be inspected prior to any roof being installed.
d. In order to receive a final,you must complete steps 1,2,and 3.
l,) Preinspectioir 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 unil inspection is required.
G. If any roof is applied without first obtaining an inspediou, you will be required to reprove all nc:v
material down to the 511=111ing and a building inspector will iuspr_t all slrc.tlning at Wal tiure.
WE UNDERS"FAND 'I'l IE A130YL• POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
IIONL OWNERS NAME: L�
ADDRESS: ' SS
REROOFING CONipj\.i lY NANLF:
APPLICANTS SIGNATURE:
• CI'IY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winrcord