R-3430 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 3430
Sy INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 252-4505EXT. 228 PERMITE90IRESIFDAYS WORK
II�SNOTSTARTED
WITSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
100O2 dm ,7Jr� F-b-fE C) L/'-C-JI"t RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
ROOF
NAME L✓�S�Kl G' ll O .'" 1 FIRE COVERING COVVERING
AREA CLASS
ADDRESS �/ t ,- �J \ EXISTING ROOF COVERING•� 11II''
PHONE NUMBER OF EXISTING COVERINGS n/V6
CONTRACTO TO BE REMOVED TO BE RETAINED
NAME hued /USNI'�-�,A,,, ^ TYPE OF ROOF COVERING
CIDTDRESSV&Z,P_321C- 1 IG GIIOG<2o �r./ '{+glifyiP 14 C-! EXISTING
S
PHONE 3p"173 g� BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hosbY affirm that I em licensed under Provision.o,Chapter 9(comment
cling with S«tion )0001 of Dlvielon 3 of Me Business and Profmions cot., WOOD SHINGLES
and my uPeaeann, ..,m.leect.
Licertee Clm onn«tor.Numbs OTHER (SPECIFY) P A I P
Dau Co
OWNER-BUILDER DECLARATION
1 Mnalbyowin area that . uempr from the Com.«torn CdaLicense Lew for OCT 14 '(103
the 1cicounty ng iCh re. ISs a oir .e, Business and Professions cone: Any=Iry PROPOSED
county wnleh r.Ra,p • Permit to construct.ralter, Improve, a folbn,or
or
eny mumu...Arlo, to in issuance,also requires the applicant Provisions
such BUILT-UP ROOF
permit o,II.•tlrted ens. Low Mn the Is II com(commencing
pursuant to Inc Prov ldom
of Na Con 3 of the Lk.nes Lew (Chapter B (cpm)or that with exempt
nthere , C117-OF
from
Division 3 0,the Business h and Pro,enime Coad A y violation Is endof S fire ASPHALT SHINGLES -
M1om ant Iia apps ,or the aPermi e.empts th Anv anttao, Section
.031.6 by any applicant t for•Permit wbjacn the wplkant to•civil pmtlry
of not more that r of ltue pro dollaerty,r my em WOOD SHAKES
❑ I,ls owner of tit.property,a or he employees with wends p their Sole
font File
(Sec.
w111 do the work, entl the structure Is not ntntla or offered
Le sale( rot apply
toaBusinessdna of
Property
Doo.: The Contractor improves
uPenp WOOD SHINGLES
Lor silo tot s ch to. lf o,prOPerty his
balds or int Pr over and that
and wno top such worn n meati or edorthrough ted own.mplovm. however,Net
such ng or improvement
are not Intended o. ns, year
for tab. It, nothevdr, the OTHER (SPECIFY)
bah dint or Intoe t e bur is sola proving
o t e di of completion, the o
bulldr will hey.tits bwem of proving Nat he aid not build or improve for
pprPs.n0 1, asowe N. property, am exclusively contracting licensed
PROVIDE I.C.B.O. REPORT NO.
ontn to construct the prolAr (Sec. .Ode, Business and Probniopcode:
The Contractor's License Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who nuuae or improve.Npwn, and who contracts for such Prol«n with is
Pntractor(s)licensed pursuant to the Contractor'.License Lew.
p ❑ I .m .vempt Pm.r s«. ,e.dP.c.to, his
..son APPLICATION DATE VALUATION PERMIT FEE
Ownsr Dare
WORKERS'COMPENSATION DECLARATION Building
I thereby elfirm that 1 have•certificate or consent to sell Insure,or a car /) p'/�
ti Nm of Wor kri Compensation Im—itrice, /oIriI a certified-copy t streo^f(S�«. /O .,/�/ ^9� 71 O v_ S81amIC
Policy No. D I Company T •H. CL'r �Mx
Dotiaed copy i.Hereto mrhith Total
C.rtifped copy Is filed with the city Impaction division.
A di di
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section head not W completed if In.Permit is for one hundred dill
Ire If 100)or Ips.)
I certify that in Ne performance o, the wort for which this Permit is r
luued, I Nell not employ any Persil y marine,'p As to become subject
to the�grk�i mgnuiion 4m r.(tallltimus L/ 7
1_ NT: 11nt 11
NOTICE TO APPLICANT: 11, • II king this Grti,icete'f Exemption,
You al oula become wbj«t to the Workers Compensation Provisions of the
Labor Dods,you must forthwith comply with such Provisions or this Permit
Nall W deamed poked. All roofs shall be Inspected prlOrtO eny roofing material being
I ...city that I have read this lipplkaron and state the,Na sow.inthnY.. Installed If a roof Is Installed without first obtaining an
It.Itis correct. I aro to comply with all city and county ordinances and inspection,I agree to remove all new materials for inspection.
nate laws laws elating to building construction, and hereby thorn. represen
ntivp of this city to enter upon the above mentioned property for inspection ,(�_ \�� /
IW.) area s. spa, indemnify costs
and kap nermlpe the in a of Cupertino Q
apimt id CITY
i c0mus usi coon ane saPenep whim may is alio war accrue ` DATE
ag.Inst eald clry m consePPenc.of me ranting of hits Permit. SIGNATURE OF APPLICANT
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
I
i
•
sSUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
I. 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 t}Pcs 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. 1f 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 T14E
POLICY
HOMEOWNERS NAME:
ADDRESS: / � g / '�jOA k Ch
REROOFING COMPANY NAME: �J �G '�N
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
RcroofAvimvord