R-4600 PERMIT
APPLICATION
4600
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL / COMMERCIAL OTHER
OWNER'S / L L HAZARDOUS FIRE AREA
NAME �/)�S N YES ❑ II yes—I understand that a Class A
roof assembly is required.
Q� �7 NO .p Initial I.C.B.O.B
ADDRESS 4� EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS L
CONTRACTOR'5 r
TO BE REMOVED�TO BE RETAINED
NAME G
ADDRESSTYPE OF ROOF COVERING
CITU 8 ZIP �
(IP / ry�L_ EXISTING
PHONE`C�� v �'U/�J BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES
C)License Class Lic.Number
OTHER(SPECIFY) ❑
Dale Contractor
OWNER-BUILDER oEcLARII PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractors License Law(Chapter 0(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
e civil penalty at not more than five hundred dollars($500).): WOOD SHAKES ❑
❑1,as owner of the property,or my employees with wages as their able compensation,will do
the work,and the structure Is not Intended for offered for sale(Sec.7044,Business and Profes-
sions 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.It,however,the building or Improvement
Is said 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,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Law tloes not PROVIDE LC.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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
r7 em exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ,p �100
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, A� wry'®A E uildinw
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this V A G+
permit is Issued. C� - ,l8 Cw TotalSeismic
have and will the pelrf Worker's Compensation the wokfor Insurance,as required by Section Worker's
's }
Ih ebor Code,for the performance of the work for which this permit is Issued.My Worker's �/ A Total
Compensa�0of Ins rance carrier and Policy number are: H LL 1g9s
Carrier 5/e �' ,uFi� Policy No. PERMIT_AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKER '
COMPENSATION INSURANCE N.C.❑
(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,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Lav all- All roofs shall be inspected prior to any rooting m terial being
forme. installed. If a roof is installed without first obtaining an
Dale APPlicont inspection,I agree to remove all new materials for inspection.
NOT CE TO PL ANT: II,after making this Ceniflc �e f Exempgm:you should become A licant understands and will Com I with all non olnt
I
subject q the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have read this application and stela that the above Information is correct agree All roof coveringstd be Class"C"or better
to complywith all city and county ordinances and state laws relating to building construction,antl
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
hpectlon purposes.
(WDO'
e)agree to save,Indemnity end keep harmless the City of Cupertino against liabilities,
judgments,coals and expenses which may in any way accrue against said City In consequence SI NATO OF APPLICANTATE
• of the granting of this permit.
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.
r 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
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HOMEOWNERS NAME: E44
ADDRESS:
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REROOFING COMPANY NAME: L �'
t
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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