R-4430 PERMIT R- 4430
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITNIN DAMS OF PERMIT ISSUANCE OR
WITH
DAYS
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS iJ�///,�/7/ BUILDING USE
`N/ CIS REST DENTIA COMMERCIAL OTHER
OWNER'SHAZ
ROOF
NAME / (� ' yy O • e FIREARDOUS „ 1 COVVERING C
/ u/�1 AREA / CLASS
ADDRESS,l t[/(D'7'/�/��CT�LiIS 1V� EXISTING ROOF COVERING
PHONE Vt t —O • NUMBER OF EXISTING COVERINGS
CONTRA R'S
TO BE REMOVED TO 8E RETAINED
NAME TYPE OF ROOF COVERING
ADDRESSl.N
clTr a zla n / X EXISTING
7
PHONE ��/ ` `] 7-77 V ` L 7 BUILT-UP ROOF
LICENSE , S ASPHALT SHINGLES
NUMBER l.� v
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I Withheredrum that 1 01 licensed .1t e 13.ions o1 id Plot a Icommem
andwins SKbon o0 of Division under of the evamo fie Prof ee, WOOD SHINGLES
end my licmee is cal o antl affect.
Licans I n Lie.Number
Date Convector OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm the, I am ...met film the Contractor's License Lew for PROPOSED
the following reason. (SK. 7031.5. Business and Professions Code: Any city
Or county which requires a Permit t0 construct, alter, Improve. demalish,o,
repair any structure,prior tom issuance,also requires the applicant for such BUILT-UP ROOF
Permit to fib a signed statement that he is licensed Pursuant to the provisions _
of the Contractor's License Lew chapter 9 (commencing with Section 70001
or Division 3 of the Business and Professions Lode)or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
or not more that rive hundred dollars($500).): WOOD SHAKES CJC
❑ I,as owner of me property, or my employees with wages as that sale
tampensation,will do.he work,and the structure is not intended or offered
r sale (Sec. 7044. Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of Property who builds or improves thereon,
and who don such work himself or through his own employees,provided that
such improvements are not intended or offeree for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
PufPosa of segs.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractorsto c nstruct the Project (Sec. 7044, Business and Professions
Lode: ThaContractor'$ Licens. Law does notsoplYtoanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves mareun, and who connects for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
sewn 1 am exempt under Sac. ,B.b P.C.for In,.
APPLICATION DATE VALUATION PERMIT FEE
Owner Dane
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to sell insure,or a car ���fff'''
t 3800?Lel Workers' L�om.�/plenution In.0 g�,ol enc•.Tjye�i Lo ra.f(Sec. P4 ® Seismic
Policy Ngr=yaLAl Company
yc,,��/.y=f=' r7J_'
8 Certified coJy sy�JG by with
II furnished. C� ® 11]�M1Q Total
Certif wins the city Inspection division. ` JLl/
Applicant �YpEl'�'�
f CEWTIFICATEOFEXEMPTION FROM WORKERS' ,7r � ' TAUTHORIZATION DATE
COMPENSATION INSURANCE N.C.❑ /'
(This section need not be completed if the permit is for one hundred dob LUNG
Ins($100)or less.) \�� �/\/
. �/
1 certify Inst in the Performance of me work for which this
Permi[ is
issued. I shall n0[am Ploy any performance
in any manner ca as 10 become eYplKt
to V Worker Compensation Laws of California,n
Orta Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption.
You should become subject to the Work.,.Campensesion provisions of the
Labor Code. You must forthwith Comply with such provisions or this permit All foots shall beins acted rlOrt080 (00110 material belts
hall be deemed evoked. p P Y g g
I certify than I have Lead this applicatlgn and stat.that the.boyo infarmA Installed If a roof is installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and IDS eC 18 t remove all new materials Porins eC110R
ante taws rest. I to building ply with on,all end hereby authorizein nes senand P n' g P
Purposes.s. this city to enter upon m•above mentioned Property for inspection /��
Purposes. (_/^y�.',`/•//
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgment$,mats and expenses Which may In any way.ccrue
a imst said City In consequence of the granting of inb Permit. S T E OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL m
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 CUPERTNO BUILDD;G DEPP.RTA IENT
PRIOR TO ISSUANCE OF PFR+NEIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply :vith U.B.C. standards and tnnnufac urers spec's
on rercofing.
2. Ne•.v roof coverings shall not be applied without first obtaining all inspecrion and «T neo approva
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,) P:einspe tion 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 firs obtaining an inspection, you will be required to remove all ne:v
material down to the sheathing and a building inspector will inspectall sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING PND WILL COMPLY WITH TIHE
POLICY
HOMEOWNERS NAME: Or/
ADDRESS::
REROOFING CONIPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILD LNG DEPARTNIENT
•
Reroof/winwdrd