R-4650 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4650
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/f 7 3 • �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YN@ '❑ If yes—I understand that a Class A
NAME All roof assembly is required.
C N Initial I.C.B.O.
ADDRESS— EXISTING ROOF COVERING
PHONE 25 S 7 Q NUMBER OF EXISTING COVERINGS
CONTRACTO
TO BE REMOVED � TO BE RETAINED
NAME 44
ADDRESS ' .(CCI/11 TYPE OF ROOF COVERING
CITY&ZIP—�/ ,AL1! • p a� EXISTING
PHON 4&R1r ` ILO $ 6 BUILT-UP ROOF ❑
LICENSE
NUMBER C ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Class Lid.Number v v v
G_� _ OTHER(SPECIFY)II n ❑
Dale T..7—Contractor
OWNER-BUILDERD LARATION PROPOSED p�
I herby of irm that I am exempt from the Contractor's License Law for the following reason. NO
V201
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-UR-ROOF O 1995 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions 01 Y(Jh
• of the Contractor's License Law(Chapter 9(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+CI{f/n,U ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
E]1.as owner of the property,or my employees with wages as their sola compensation,will do ❑
the work,and the structure Is not intended or offered for Sale(Sec.7044,Business and Profes-
sions Code:The Contractors 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 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 N . 43s 1
apply to an ownerof property who builds or Improves thereon,and who cantracts for Such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE li INSTALLATION SPECS.
❑I am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PER T FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, to Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
perm s Issue. 17�J4 /� (��� /
have and will maintaln Worker's Compensation Insurance,as required by Section 3700 of {{{'' Seismic
Labor Code,for the performance of the work for which this permit Is Issued.My Workers
ompensation Insurance c rrier and Policy number are: /� Total
Carrier PolicyNo.'(t(I[IC &42?1200) PERMITA ZATION D
CERTIFICATE OF MPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit IS for one hundred dollars($100)or less.)
I cattily that in the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to become Subject to the Workers'Compensation Lewa of Celi 00} shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NTICE TO APPLIANT: 1,after oshoulecome
subs at o the Worrkerss'Compefnsatio prrovisions ofatheil born Code,you mf Exemption,ust fo thwidthbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the some information Is correct agree
to comply with all city and county ordinances and state laws relating 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.
ape purposes. /` ?
(We)Am)agree to save,indemnify and keep harmless the City /`
of Cupertino against liabilities, � !/ 7
• judgments,costs and expenses which may In any way accrue against Said City in consequence SIGNATURE OF APPLICANT DATE
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 ACCESSTO 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.
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: / Zw�
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE: Q
CITY OF CUPERTINO
BUILDING DEPARTMENT
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