R-4072 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITH(N 180 DAYS OF WORK
ISSUANCE OR
IBI(DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS3z3 BUILDING USE
d2 L,C)J O ` . CON RESIDENTIAL COMMERCIAL OTHER
OWNER'S +r._rL�`} /�y,
ROOF
NAME �d` ` " \ '11 '� \' ` O\ • " �` '1 FIREAREHAZARDOUS N� COLASS VERING ��-.4
ADDRESS Ivo/(TVA/Po hT �,.J V EXISTING ROOF COVERING' I\
PHONE I Z ^t0 3 ( NUMBER OF EXISTING COVERINGS
CONTRAC OR's ;Y--D
NAME Q O'�` J O C-2 TO BE REMOVED ` TO BE RETAINED
TYPE OF ROOF COVERING
CITY&ish Q��S �^� 7S 7th +� EXISTING
PHONE I 71 — / S00 BUILT-UP ROOF
LICENSEZ,UI� ASPHALT SHINGLES n/
NUMBER WOOD SHAKES ry
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under ptoyismns of chapter 9 my with Section 7000) of Division 3 of the Business and Professions Coda,(common. WOOD SHINGLES
and my license h 1 rca and eliect. ,,11 .ws�`� np,�
Dote License Cl • �f Contractorer Y &Cf - OTHER (SPECIFY)
OWNERBUILDE R DECLARATION J
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
or county which requires a permit to construct,alter, improve, demolish,or
tape lr env structure,Prior m its issuance, also requires the applicant for such BUILT-UP ROOF
permit to Ill.•signed to
mat he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt more ASPHALT SHINGLES
from and the bests for the alleged ...mplion. Any violation of S. Ii.P
7031.5 by any applicant for a permit++5001.1: WOOD SHAKES
ubjects the applicant to a civil penalty
o1 not more that five no noted donors(s
❑ I, es owner o1 the property, or my employees with w....+their sole
compensation,will do the work, and the structure is not intended o oliered
o
for le(Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who build,.1 improver thereon,
and who don such work himself or through his own employees,provided that I
beach improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
uilding or improvement sold within one rear of completion, the owner
builder will nava the burden of proving that he did not build or improve for
purpose ere PROVIDE I.C.B.O. REPORT NO.
❑ I, + owner ji 11 property, t ( asst lu044. Gutman an with licensed
.do: her. to construct he project does
t app Gutman anowner
and f propeons
rty code: The 0, impcure$ License and who cot tracts fotuch projects with
PROVIDE MFGR. INSTALLATION SPECS.
who build+ )licensed
t thereon,t and who contracts for such projects with a
contract am l emptd under
Spursuant[o ma Connector's License Law. _
❑ 1 em exempt under Sec. ,B.&P.C.for this
..wenn APPLICATIO19 DATEI VALUATION PERMIT FEE
Owns. Dad -
WORKERS'COMPENSATIONDECLARATION IIA( (li ���� Building
I hereby affirm son have i n I n uran , courant to del PY th r or a ter. v(� IY
3111, of Wo.ke.i Compan+anon lm r nca,ora<aanetl copy m roof(Sec .1V13 O Seismic �� /y
Polio.Lob.Cy>Ib7/4 company S''�'a�¢ 1�—uhC.{ Cil UP L Q L�—r�L}/e
Policy Certified
BCarti iea espy is hereby turn iched. Ur'tryll(yU Total
canined�cogr burcity s cion diyb�on.
Applicant C
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.O PERMIT AUTHORIZATION DATE
COMPENSATI O NINSURANCE
(This section need not be completed if the permit is for one hundred dot
ISIS 151001 or lees.)
I certify that in the performance of the work for which this permit is
issued, I that not employ any person in any manner 10 as to become subject
to the Worker.'Compensation Laws of California.
Dad Applicant
NOTICE TO APPLICANT: ll, after making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit All roofsshall be Inspected prlortoany roofing material being
.hotI be domed rwoked.
I certify that I It...toad this SpplicafiCn and state Ines the above inform. Installed If a roof IS Installed Without first obtaining an
non is W. ela I torn m comply with an city am by nay orto n end i n,I rem 0 neW m ref IS for IR8 eCtIOR
tine laws nit.I m building ply with all and hereby authorize to "an.
..Sivas of this city to enter upon the above Mentioned property for inspection
purpose+. rt
IWtI agru to uv indemnify and keep hermdes the City of Cupertino 7
against liabilities, conse see,cobs and eapensn which er in any way accrue
against said city in consequence of the granting of mit permit. S NATUflE OF APPLICANT DAT
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
i
SUBIECI': REROOFING POLICY FOR 771E CITY OF CUPERTINO BUILDING DEPARTrb1ENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you roust agree to comply wilh U.B.C. standards and manufacturers spec's
o" reroofing.
2. New roof coverings sliall not be applied willnout first obtaining all inspection and wrilten approval
from the building inspector. A finial 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 roorbei"g installed.
d. In order to receive a final,you "lust complete steps 1, 2, and 3.
1,) Preinspectio"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.
G. If any roof is applied without first obtaining on 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 TILE
POLICY
HOMEOWNERS NAME: Nam- r n I
ADDRESS: 1Z��s� Nom r wy
REROOFING CONIPANYNAIv1E:
APPLICANTS SIGNATURE:
• C17`Y OF CUPERTINO
BUILDING DEPARTNIENT
Rercof/wimvord