R-3971L�J
OFFICE COPY
PERMIT R_ 3971
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT
EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
mishea AwSe.J AVE
RESIDENTIAL "' COMMERCIAL OTHER
OWNER'S
,I `pt+
uev ILLS 0waLL
HAZARDOUS ROOF
NAME
FIRE AREA CLASS COVERINGA.
ADDRESS163tle Aya.^.l A4¢
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
I Z 3
PHONE [z
O
CONTRACTOR'S
(M LAo4S�
TO BE REMOVED TO BE RETAINED
15008 TYPE OF ROOF COVERING
NAME h ��
ADDRESS
CITY & ZIP lbo 5 5A.4 TailAI1f AQV iliIp
EXISTING
BUILT-UP ROOF
9 —01;0 00)
PHONE—
LICENSEZ / �,�,', '7 LL�
ASPHALT SHINGLES
NUMBER � t
LICENSED CONTRACTORS DECLARATION
I herby affirm 7000 I of licensed under provisions of Chapter 9 (commee,
cissa with section 7000) of Division 3 of the Business a Profeniom cone,
INGLES
and my license I+ In ll farce end affect (4� �aj
Licanu Cb Lin. Number i� T
Data con7r«m.0�
OW E BUILDER DECLARATION
PEC -Y) g
I hereby affirm that I am exempt nom the Contrsctoi s License Lew for
tn. following reason. (S«. 7031.5, Business and Professions Code: Any city
)ASPAL
or county which requires a permit to construct, alter, Improve, demolim,or
/
repair any structure, prior to it, issuance, also requires me applicant for such
F\
Permit to III. ° .i areae statement that he is licensed pursuant to the provisions
p1 the Contractor's Licame Lew (Chapter 9 (commencing With Section 7000)
of Division 3 of the Business and Professions Codel or that he is exempt there
t
from for
S I GLES I
and the basis the alleged exemption. Any violation of S«tion
7031.5 bV any applicant for a permit subjects the applicant to ° civil penalty
0i nor more that five hundred dollen (500).):
AKES❑
I, as owner of m°property, a my employees with wages as their sole
compensation,will do the work, andrthe structure is not intended o offered
for sale (Sec. 7044,Bufineas end Professions Code: The Contractor's License
IN
Lew don not apply to an owner of Property who builds or imp,ova+rh......
and who don such work himself or through his own employees, provided that
such improvements are not intended or offered for sale If, however, the
OTHER (SPECIFY)
building or improvement is +old within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
Purpose of sale.).
PROVIDE I.C.B.O. REPORT NO.
C3 I,s owner of the properly, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: Th a Contractor's License Law do., not apply to an owner of Property
PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves theraun, and who contracts for such projects with a
contractor(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt unser sac. ,B.aP.c. for his
mon
APPLICATION DATE
VALUATION
PERMIT FEE
Ow 0.1.
WORKERSCOMPENSATION DECLARATION
Building
I hereby affirm that I have a certificate of consent to sell insure, or a car
tificata of Workers' Compensation Insurance, or a certified copy hereof (Sec.
PAID
t
1
Seismic
3800, C.). sY�«
N
/�
No ZJWn
Policy No. Company h
/""1V//P
Cartifiad copy is h b p reed. /J
Certified co d l{p/Iha cid insarasw"n nivisi"✓
�/�
as
6
Total
Appbcant JI/ r Iar��
.� MIT AUTHORIZATION TE
/�)
CERTIFICATE OF EXEMPTION F M WORKERS' N.C. ❑ C/�'
VuN'
tn!!ryp
COMPENSATION INSU ANCEI'
(This action head not be completed if the is for one hundred deb
permit
I.r. (5100) .r less.)
I clsfifv that in me p.rform°nca of In.work for which his PermitI.
issued, I Nell not employ any person in any manner so es to become subject
to the Workeri ComVensatlon Laws of California.
Data Applicant
NOTICE TO APPLICANT: It, otter making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions o1 the
Labor Code, you must forthwith comply with such provisions or this permit
All roofs shall be inspected prior to any roofing material being
hall be rimmed ravoksd.
I certify that I have read misapplication and state that the above informs
installed If a roof is Installed without first obtaining an
to i+ l °o'°° to `°r"°ly wit all °l' `trey and `°u;uy °'ei"';`°' and
inspection, I agree to remove all new materials for inspection.
w. rate
rt'a laws lacing to building construction, e d hereby horiz presam
Otiyes or this city to enter upon the .'Ove -mentioned property for inspection
pPr(We) save, indemnity and
(Wt) •pins City of Cupertino
themay
es Which
expenses
ageimt laid Cbas. corse iso cosh end e.p.nses which maY in my wry accrue
s.
awinsf+.irk city in consaquanga of the graining or this permit
SIGNATURE OF APPLICANT D E
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
0µ
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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.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.
Q Preiirspection 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.
G. 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
Reroof/wimvord