R-4596•
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OFFICE COPY
PERMIT R_ 4596
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I LJ I d '2D �(� C 2 7 L.'Iv
RESIDENTIAL—L_ COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
CC
��G�)2�� �I�IL-,DV
YES ❑ If stand Class
NAME
assembly is required.
roof assembly Is requlrat
NO Initial I.C.B.O. H
+ n -
1 Li I 1`�S�G
EXISTING ROOF COVERING
ADDRESS
�5 tea,
NUMBER OF EXISTING COVERINGS
PHONE o
CONTRACTOR'S��jj
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS - 1 Lo / I S 1 I C 1-} LIN #�-�
_T_YPE OF ROOF COVERING
CIN 8 ZIP
EXISTING
EXISTING
-
PHONE _ U'-7i� -
BUILT-UP ROOF ❑
CENSE
NUMBER (--�91 o
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Cotle, and my license is in full force and
affect. 2G
C J I ,.J�� 3 2 o '
WOOD SHINGLES ❑
Cleanse Class Lic. Number
Date 9 / X-) 25 Contractor Qe- a l 4
OTHER (SPECIFY) ❑
PROPOSED
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
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(Sac. 7031.5, Business and Professions Code: Any city or county which requires a permit to
onstruct, 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
Contractor's Lew Section 7000) Division 3
of the License (Chapter 9 (commencing with of 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 colt 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 (Sac. 7044, Business and Profen
slons Code: 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, 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 contractors) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B Is P. C. for this reason
n
6—
owner Date
PPLICATION DATE
VALUATION
PE
IT EE
WORKER'S COMPENSATION DECLARATION
(�
O 1x795
I h r -by affirm under penalty of perjury one of the following declaration:
t ,
for Worker's Compensation,
Consent the
�haye anded t3700
Building
as provided far by Section 3700 of the Labor Code, for the padnsu,a
Sectiill on
for of the1 Late bor performance of the work for which thin
)l
permit is issued.
1 have maintain Worker's Compensation Insurance, as required by Section 3700 of
UI- uurtHf
Seismic
❑ antl will
INU
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Total
Compensation carrier and Policy number are:
�Z)9116
PERMIT AUTHORIZATION
DATE
`Insurance
carner.�A(, 17-1_ V2L-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit IS Issue J, I shall not employ
any person In any manner so as to become subject o the Workers'Camps ation Laws of call-
All roofs shall be inspected prior to any r ofing material being
forma,
installed. If a roof is installed without first obtaining an
%ln 1�
Date `� Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
NOTICE Os'sdlluutibecome
subject to the Workers' Compensation provisions the Labor Code, you mstforhwthcomply
with such provislons 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 1 agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof erings to be cls -9 "C" or be r.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
�H
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
LC/
judgments, costs and expenses which may in any way accrue against said City In consequence
I RE AP ANT DTE
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
of.
Cupertino
•
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I understand and comply with Section 1210-A of the Uniform Building Code.
Section 1210-A requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping 'room and at a
point centrally located in the corridor or area giving access to room used for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE
DATE:
winword/smkdet
4ll
zpp /9'9f
Printed an Recycled Paper
0
7
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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
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