R-3943 PERMIT R_ 3943
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMITMIT
(408) 252-4505 EXT. 228 WITHIN EXPIRES80 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS (` �`n' BUILDING USE
tZ I -73 (1jyL v' RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �) O 1 I7/LJ FIRE � )d COVERING
/ YJ� ,, _0 AREA wi CLASS
ADDRESS 'Z/ ?/3 6 i r.r �rir 4�'L� (:� EXISTING ROOF COVERING
PHONE "'� 4 v 2 O NUMBER OF EXISTING COVERINGS
CONTRACT 'S
�� R
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
RESS
CIDTD&ZI0 a F�
(/Y,// "� �7 C q EXISTING
PHONE I"7 tU !C�fJ -/ / BUILT-UP ROOF
NLICENSEUMBER Z I �1I ASPHALT SHINGLES
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed undes provision.of Chapter 9(common
Ging with Section TOM) of Division 3 of the Business and Professions Coda, WOOD SHINGLES
and my license if i r�fulLf�a ens effect �/
License Cl .J Li<.Number
Dat. 7P Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coda: Any city
Or county which require. a permit t0 Construct, alar, improve,dem dish..,
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
of the Contractor i License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
• from and the basis for the alleged exemption. Any violation of Section
.5
7031by any applicant for a permitubjecn the applicant to a civil penatry
of not more met five hundred dollars($500).): WOOD SHAKES
❑ 1,as Owner of the property. or my emVloven with wages as their Sole
compensation, will do the work, and me structure is not intended or offeree WOOD SHINGLES
for sale(Sec. 7044, Business and Professions Coda: Th.Contractor's License
Lew 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 improvement, ere nor intended or offered for vele. 11, however, the OTHER (SPECIFY)
building or improvement I. sola 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.
❑ 1, as owner of the property, a exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Profession.
Code: The Contractors License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve. thereon, and who contracts for such projects wit- a
contrector O)lse
icend pursuent to the Contractor's License Law.
reason am exempt under sec. ,B.sP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dots
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm me[ I have a certificate of consent to sell insure,or a
tificaa of Workers'Compensation Insur ce,or acartifi d py mereoi Ica<. 14
� seismic
3800,La / �1 �f/Q�///. PAID
Pony N 9'4692Qompanr �-zap- ea/'Yo M I
Celitis ietl torr�. eery furnished ps Total
Gr[Iliad c flu wit ate cit.i�(o tion IY
Apl ant 4 / �� KQ,Q.,, ion.
CERTIFICA E OF EXEMPTIONROM WORKERS' MIT AUTHORIZATION DATE
COMPENSATI O NINSURANCE N-C-� ,'``fr
(This• ction need not be complabd if the Permit is for one hundred dol-
�' / 1 I/
let.(E1oDl pr I...l OVrtlYl/IYU `
I cattily that in the performance of the work for which this permit if
issued, I Nell not employ any parson In any manner so as to become subject
to the Workers'Compensation Lew.of California.
Data es Applicant
NOTICE TO APPLICANT: If, Allen
rtmaking his Cenem
ificete of Exemption,
Exemption,..
should become subject 10 the Work.,$ Compensation provisions of the
Labor Code,you mon forthwith comply with such provisions or this permit All roofs shell be inspected prlorto anylioofing material being
.hell be threshold revoked.
I certify that 1 have read this application and state that the above informs. Installed. If a roof Is Installed without first obtaining an
eon I. coir«t. 1 .'res to comply with all city and county ordinances and inspectio ree to move all new materialsfor inspection.
state lam fainting to building construction, and hereby authorize repression
taeves of this city to anter upon the above mentioned property for inspection
purpose..
(We) earn to ave, indemnify and keep hornless the City of Cupertino
against liabilities,judgments,casts and expenses which may In any way accrue 91
.,met sale City in consequence of the granting m this permit. SIGNAT E OF APPLICANT DATE
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
SUBIECI': REROOFING POLICY FOR 771E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMfT AND INSPECTION PHASE.
L Prior to perulit issuance, you must agree to comply with U.B.C. standards and manufacturers specs
Oil reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from lire building inspector. A final iuspeclion and approval shall be obtained from lire 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.
I J Preinspeclion or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
bJ 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: -21 3 6 Qom✓ l�
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
Reroof/wiuword