R-3630 3 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 3630
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1 - ;d N0 f0c rc- S RESIDENTIAL OMMERCIAL OTHER
OWNER'S ��QQ-}-'u
NAME ,�o 1 �Ci• I (� HAZARDOUS ROOF
FIRE COVERING
\ r AREA CLASS
ADDRESS I o 8oo D N otrH P0(IST- Z e ;q EXISTING ROOF COVERING
PHONE (14 — �=.3 NUMBER OF EXISTING COVERINGS '
CONTRA R'S
A /_oR 101 F l G- TO BE REMOVED TO BE RETAINED
NAME � y ANT TYPE OF ROOF COVERING ,
ADDRESS ( 215- sic• 2 S" �`��r 7SPHA
EIN
PHONEg7/- �?\500 LspU
LICENSE ,/ '_ SHIN L SNUMBER '"tU o KRY�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed mo provision.of Chapter 9(comm.m MOOD SHINGLES
aing with Section 7000) of Division 3 of the Business and^P,.I.WOCoda,
m nd my Iic.n..I.In ll fpr Ilett. T r
License Off Lic.Number
Data Comrecto• FIN OTHER (SPECIFY)
JOVAEllt BUILDER OECLAR TION
I ho.by affirm that I am exempt from me Contractors License Lew for PROPOSED
the following n . (Sec. 7031.&, Business and Professions Code: Any ci W
or county which rea Permit to construct,alter,improv., damolisn,or
r.P.ir 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's License Law (Chapter 9 (commencing with Section 7000)
' of Division 3 of the Bmine.s no Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a Parmi[ ubjects the applicant to a civil Penalty
of not more that five hundred dollars(S500).t: WOOD SHAKES
❑ I,as owner of the properly,or my employees with wages as their sole
compensation,will do me work, and the structure is not intended or offeree WOOD SHINGLES
for sale (Sec. 7044, Business and Profess ions Coda: The Contractor's License
Law does not apply toe o OI Property who builds or imprli thereon,
and who does such work himself Or through his own employees,Provided that Lod
�•rr M
such improvements are not int.nd.d o offered for sale. u, how.v.r, he OTHER (SPECIFY) '71 C od � gmg�
buildi ng or improvement i sold within one year of completion, the o r
build.,will have the burden of proving that he did not build or improvefor
purpose.1..l..l. PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, a exclusively contracting with licensed
contractorsto construct the project (Sac. 7044, Business and Professions
Code: Tho Contractor's License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contractofs),licensed pursuant to the Contractor's License Lew:
❑ I am exempt under Sec. ,B.&P.C.for this
APPLICATION DATE VALUATION PERMIT FEE
owner Dat.
WORKERS'COMPENSATION DECLARATION ,t� S_ Building ,3r7a,
I hereby effirm that I nava a certificate of consent to self-ins `VS p
tificete of Workeri Comp....lion Insuranc o certified copy thereof(Sec. Seismic
],3D
3800,Lab.c�, _, x , e [' 1-AT� �-'/ ) 1 D T
Policy No.G[-L-[fQ_f-Iu�C111.3 nY J l _1 I r�f/l LCL P A 10
BCerit d Copf hereby furrJ a I Total
Cartifbd 24 IllV ithytf}!city�id6 division.
Applicant �✓;1p�DT/' _ilu-YY��/p�-rr/a{"' /
CERTfFICATE OF EXEMPTION FROM WORKERS' N C ❑ API,
PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This rection nerd not be completed it the Permit is$10fes.one nundnd Ool/xll"
Irts(c." Orless.l l// ii r VUr[nluv
I [artily [not in the performance of the work for whichmit permit i. V
issued, I shell not employany person in my manasner so e.m become subject '
to the Work.,.'Com Compensation
setlon Law.of C.lilornia.
Oats NT:AppIf,t
an
NOTICE should
APPLICANT: o alto making this Certificate of Exemption,
you r Cole become subject i h c Workers' Compensation nso r inns of the
Labor Coaa, you must forthwith comply with such provisions or [M1if permit All roofs shall be Inspected prior toany roofing material being
shell be deemed revoked.
lcertify that I nava read this appliceaon and.xata mat he above Informs Installed If a roof IS Installed without first obtaining an
tion if correct. 1 egrets to comply with all city and county ordinances.redJess [tion,I agree to removeall new materials for inspection.
at... I.. r.eling to building construction, and hereby author i 1. I.Pmam
tatives OI this city[O enter upon the above-mentioned property for inspection
purpIWaI oses.
aures s, save, indemnify end keep es which
the City of Cupertino
against liabilities,lodgments,cons and expense.wbks mem in any way acvua -
ewimt said City in consequence of the gnnbnq of this permit. SIGNATURE OF'APPLICANT DAIE
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
SUBJECT: REROOFING POLICY FOR THE CITY Of CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OP PERMIT AND INSPEC"TION PRASE.
1. Prior to permit issuance, you nmsl agree (o comply with U.D.C. standards and manufacturers spee's
Oil rcroofing.
2. New roof coverings shall not be applicd without fiisl obtaining all inspection and written approval
from lire building inspcc(or. A final inspection and approval shall be oblained from the building
inspector when the rcroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
A. In order(o receive a final,you must complete steps I, 2, and 3.
I J Prcinspcclion or [car off approval.
2.) In progress inspection approval. '
3.) Final inspection approval.
a.) Operable smoke detector veriricalion
b.) Spark arrestor ins(allalion
5. If plywood is installed, a plywood nail inspection is required.
G. If any roof is applied without first obtaining an inspcc6on, you will be required to remove all new
material (1011,11 (o the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY r /�
IIOMEOWNERS NAME: NGIA r I t I NT r ` O� A�
ADDRESS: I oro o N0R-rHPD462,t)10-T- G
REROOFING COMPANY NAME: T X l /-OR /? 0eq l ( N
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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