R 4180 PERMIT
APPLICATION FOR1� CITY OF CUPERTINO NUMBERRAs 4180
REROOF PERMIT (408) 252-4505 EXT. 228 INSPECTION DIVISION PERMIT EXPIRATION
Jl, PERMIT EXPIRES IF WORK IS NOT STARTED
J WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRrss B1ftDING USE
RESIDENTIAL L COMMERCIAL OTHER
OWNER'S 1
HAZARDOUS ROOF
NAME / ✓ AREA CLASS COVERING
ADDRESS_ n/42� EXISTING ROOF COVERING
PHONE (/ �'7l61.-3"5 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME C• n TYPE OF ROOF COVERING
CDD a
ADDRESS �G CII�IJ
XISTING
PHONE I�W / _ /7 Y BUILT-UP ROOF
~ LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby Section
7000) of licensed under provisions of Chapter B(commdo
clop with section 7000) of Division 3 of the Business n P nions,Caae WOOD SHINGLES
and mV license is In f/IJ r ane affect
License cls« Lk. ractp,froOTHER (SPECIFY)
Oats 11c.C.nIN for
NER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License easdLaw for PROPOSED
the fallowing ron. (Sac. 7031.5, Business and Professions Coda:: Any ny coy
or county which requires • permit to construct, e1Lr, improve,demollsh,or
repair any structure,Prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Permit to fila a signed statement that he is licensed pursuant to the provisions �/I V
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) A 1 �(1
' of Division 3 of the Business and Professions Code)or that he is exempt there" ASPHALT SHINGLES 9C
9
from and the basis for the alleged exemption. Any violation of Section
7031.8 by any applicant for a permit subjects the applicant to a civil penalty �'I
of not more that five hundred dollars($500).1: WOOD SHAKES Y or-
[3 Vim' �r f ul.t i
I,o Owner Of the property.Or my ampl,,."with wages es their sola
compensation,will do the work, and the structure is not intended or offered
for &Is(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, f,
and who does such work himself or through his own employees,Provided that tn�v�l(�-,L,
such imProvemants are not intended or offered for fele. 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
purppse Of sale.). PROVIDE I.C.B.O. REPORT q
0 I, as owner of the properly, am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Code: The Contractor's License Low does not apply to an own.,of Property PROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves thereon, and Who Contracts for such projects with a
comrxmr(s)licensed pursuant to the Contractors License Law.
.oam exempt under Sec. ,B.aP.c.for role
r.. n APPLICATION DATE VALUATION PERMIT FEE
Owner Dna
WORKERS'COMPENSATION DECLARATION `'1� Building
hereby eruct that 1have ocertilicete of comm[to esll"Insure,or•car /7�/t
�IO�office«ab WorA,9/47 ioD Imu,A7 •a ntifie espy t ereo119ac. /� -
3800, Lab. ,1 ft/` —`rd\lY/. Seismic
Polo O. O pany
Cer.....a copy is In b furnishad.
Certified copy is III t itV"flspect'On tlivisi ( Total
DDliunl
CERTIFICATE O X Pfl 0'NF'q M W AKI RS• PERMIT RIZATION DATE
COMPENSATION INSURAC'
(Thio section need not be completed if the Wit is for one hundred dol"
Ian($100)or less.)
I certify that in the performance at the work for which this permit is
issued. I shell not employ any person in any manner so as to become subject
to the Workers'Compensation Laws Of California.
Dote Appllcant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You should become subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit
thaAll roofashell be e
than be deemed revoked. Inspected prlorto any roofing material being
I certify that I nava read this application and state that the move Inform. Installed. If a roof IS Installed without first obtaining an
tion is correct. I agree to comply with .I1 city and county ordinances and Ing action a reetoremoveall ewmaterialsforina
.tate Tawe relating to building construction, and hereby authorize represm. p 4J pe tion.
Purpoof this city to corn upon the above mentioned Property for impaction
t ives of
(W.j agres to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in consequence of the granting of this permit. SIGNATU AP LIC N DATE
PRE-INSPECTION: PLYWOOD: IN-PRO ESS:
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
SUBJECT. REROOFING POLICY FOR TIIE CI'IY OF CUPERTINO BUILDING DEPARTMENT
PRIORTO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issunnce, you must agree to comply with U.B.C. standards and nanufacturcrs spec's
Oil reroofing.
2. New roar coverings shall not be applied without first obtaining all inspection and written approval
rronn the building huspcctor. A final inspection and approval shall be obtained from the building
inspector when tirereroofing is completed.
3. All types or roorshall be inspected prior to any roorbeing installed.
4. In order to receive a final,you crust complete steps 1,2, and 3.
1,) Preinspeclioir or tear of approval.
2.) In progress inspection npprovnl.
• 3.) Final inspection approval.
a.) Operable smoke detector veriricn(ion
b.) Spark arrestor installation
5. Irplywood is installed, a plywood nail inspection is required.
6. Ir any roar is applied willrout first obtaining nm inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at[lint lime.
WE UNDERSTAND T11E A13OVE POLICY ON REROOFING AND WILL COMPLY WITII TILE
POLICY n
IIOIv1L•OWNERS NAME: ` r
ADDRESS: �a
J
REROOFING COMPANY NANIE:
APPLICANTS SIGNATURE:
• CI'1"Y OF CUPERTINO
BUILDING DEPARTNIENT
Rcroor/wiimord