R-4075 PERMIT R_ 4075
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOWPERM TISSUANCE OR
180 DAyS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
D (03(07- I'�a` 1 vpAVIt <3 RESIDENTIAL COMMERCIAL OTHER
OWNER'S //Q�•-
NAME ' vim` " ' �'-"" ' �•" - FIRE OUS D CLASS A
` \ FIRE COVERING
ADDRESS/ i�O� IJN�o+�T �'�/4l EXISTING ROOF COVERING
PHONE ` 15) ;�5L — (p.3I NUMBER OF EXISTING COVERINGS `
CONTRACTOR
�4 C TO BE REMOVED TO BE RETAINED
NAME I A O!� O. TYPE OF ROOF COVERING
CIITDY&Zlb �C✓� S �•• EXISTING
PHONE 977 50n BUILT-UP ROOF
a
LICENSE /,L �� ASPHALT SHINGLES
NUMBER "7 d O K
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I WithhereSection affirm 00 of lipm.e under provisions of Ch Profs 9...(comman
and with ens. Tt ofad Division f 9 m the Business and P.oas.mn.cod., WOOD SHINGLES
Lid mst license i. 1 11 and Peen.
ucanu Cl • nCi Lia Numb.. �$2010
Date Com,«tor ..- OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sac. 7001.6, Business and Professions Code: Any city
or county which requires a permit to construct, alto,improve, Eamalish,or
repair any structure, Prior to its issuance,also requires the applicant for auto BUILT-UP ROOF
Permit to file A sign..statement that he is licensed pursuant to the provisions
of in•Contractor's License Law (Chapter 9 (commencing with Section 7000)
oI Divind the me Business the
.all Professions tion.)or that he is exempt thelia' ASPHALT SHINGLES
from .red tat. bases far the and
alleged exemption. Any violation of Section
7001.6 by any applicant for a permit subjectsthe applicant to a civil penalty
of not more that five hundred dollars(6600).): WOOD SHAKES
❑ I,a r of the property, or my employees with wages as their sole
Compans.tion'will do[ate work, and the structure is not intended Or offeree
for sets (Sec 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does net apply to an owner of property who builds or improves[hereon,
and who does such work himself Or through his own employees,Provided that
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) 1,�za Jy1
building or improvement b sold 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.
❑ I, as owner Of the property, am exclusively contracting with licensed
Contra [o construct the project (Sec. 7044, Business and Professions
Code: Tate Contractor's Lic.ns. Law does not apply to an owner of property PROVIDE fill INSTALLATION SPECS.
who builds or improves theaun,and who contracts for such Projects with a
contractor(s)lcern
ed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,8.&P.C.for this
,anon APPLICATION DATE VALUATION PERMIT FEE
Owner Date pg�� pp
is
WORKERS'COMPENSATION DECLARATION fly I D Building21f-EIG
I hereby Affirm that 1 have a certificate of consent to self insure,or a car.
titicau of Workeri Compensation Inmr er a cop Thereof(Sec. p9 tj•� / I' �QO $elamlC
0800, No b'%,b?,i rGw'-l0� UN N1
Policy ab Company �/ �/yy���yyC
E Certified copy is hereby W,nisr•e. 995 Total
Certified cgyy s fileQ with EI]1 t .cnpn division.Applicant
Applicant rJ�ra.JO 1L�G l/�I r.• ,-
CER FICATE OF EXEMPTION FROM WORKERS' N D v ' PE'RMfT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
los($100)or Ins.)
cartify that n Me performance Of the work for which this permit i
issued, i
I Mell not. ploy any parson in any manner so as to become aubj«t
to tete Workeri Compensation Laws of California.
MAOPlican[
ICE TO APPLICANT: If, attar making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of tat•
Labor Code,you must forthwith comply with such provisions or this permit
snap be deemed revoked. All roofs shall be inspected prior to any roofing material being
I certify that I have read this application and Stan that the above informs. Installed If a roof Is Installed without first obtaining an
non Is tor.«t. I .gr.. tp .amply with all city and county ordinances and inspection,I agree to remove all n w materials for inspection.
at.se laws reining to building construction, and hereby authorize apasen
...wes of this city to enter upon the abovementioned property for inspection
purposes.
(We) agree to save, indemnify and keep hermins the City of Cupertino 'j�
against liabilities,judgents,costs and expanses which may In any way accrue
against said City in consequence of the granting of this permit. ATURE OF APPLICANT IDA11t
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
SUB1ECl': REROOFING POLICY FOR TIIr- CPIY OF CUPERTINO BUILDING DEPARTI ENf
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you roust agree to comply willr 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 front lire building
inspector when the rcroofnng is connplcicd.
3. All types of roof shall be inspected prior to ally roof being installed.
d. lu order to receive a final,you must complete steps 1,2, and 3.
1,) preinspectiorl or tear off approval.
2.) lu progress itspcclion 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.
G. If any roof is applied without first obtaining ant inspection, you will be required to remove all new
material down to Une sheathing and a building inspector Will inspect all sheathing at Unat little.
WE UNDERSTAND 171E A13OVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY 1\ \
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NA,VIE: Q QT 1��6r
APPLICANTS SIGNATURE:
• CI'IY OF CUPERTINO
BUILDING DEPARTivIENT
Reroof/wimeord