R-4636 (2) PERMIT R_ 4636
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
LI I�
O Z Vl IDENTIi COMMERCIAL OTHER
OWNE 's _ HAZARDOUS FIRE AREA
YES F] If as—I understand that a Class A
NAMEILLn .of
assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS
EXISTING F CO ERING
—
NUMBER OF EXISTING COVERINGS a�
PHONE
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME
ADORES ' TYPE OF ROOF COVERING
I clTv a nP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
UM13EFI
NASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION - •�
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHADES
]000)of Division 3 of the Winess and Professions Code,and my license Is in full force and
effect' WOOD SHINGLES E]License Cle Lic.Number
4
Dais
OTHER (SPECIFY) E]` _ C
NERBUonirector ILDER DE V
hereby affirm that a exempt from the Contractor's License Lew for the following revs n.
PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permi to
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to his a sli statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Divisl(tn 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 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.]044,Business and Profes-
stonsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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 Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO.QJ—
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 M FGR.INSTALLATION SPECS.
❑1 am exempt under Sec. .B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following federation; /�
❑ have and will maintain a of thel Lab r Consent to performance
for Worker's Compensation,which
this I Building
as mit is for by Section 3700 of the Labor Code,for the pedormance of the work for which this 'JJ J 1\ ��
permit is issued.an Seismic .90
❑I have and will maintain Worker's Compena tion Insurance,es requiratl by Section 3700 of
tha Labor o ,for the performanc the wo for which this Perm
Is Iit of.My Worker's Total
Comp sat In ra ce rier Poiicy nu er ere: I ^
Carrier Pollcy N . I-1 GJ 95 PERMIT AUTHORIZATION DATE
CE *IFICTEOF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) 7
I certify that In the Performance of the work for which this permit Is Issued,I shall not employ
any person In any magner so as ro become to t w rkers ampensauon Laws of call. All roofs shall be inspected prior to any roofing material being
form . lye installed. If a roof is installed without first obtaining an
Dae Applicant inspection,I agree to remove all new materials for inspection.
NO ICE 70 APPLICANT: II,alter making this Cer tfic to of Exemption,you shoo become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of tha V. bor Code,you must forthwith comply
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 state laws relating to building construction,and AI ,coverings to be a "C"or better. I
hereby authorize representatives of this city to enter upon the above-mentloned property for in- Ir
p y�
spection purposes. Al l
(We)agree to save,indemnity and keep harmless the City of Cupertino agalnst liabllitlas,
ofthe gran costs end expenses which may In any way accrue against said City Inconsequence SIGNATURE OF APPLICANT ATE
of the encs,cg of thisand permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP, DATE INSP. DATE I;"111NU
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP.-DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
i
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 RER OFING AND WILL COMPLY WITH THE
POLICY �1
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NANIE: v C Q
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword