R-4001 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER R- 4001
REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION
2408) 252-4505 EXT, 228 PERMITOT STARTED
THIN 180 DAYS OF PERM ORK IS TISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS . / BUILDING USE
2,01 lil;�11141 4 RESIDENTIAL V COMMERCIAL OTHER
OWNER'S
_ HAZARDOUS ROOF
NAME L1 COVERING
AREA CLASS
ADDRESS l�� Y / �uF�GiG?— EXISTING ROOF COVERING
PHONE ;7�23 —��/� NUMBER OF EXISTING COVERINGS /
CONTRACT�O//q'S TO BE REMOVED TO BE RETAINED
NAME 1Ztpg4l 1'ej f�J�wi J� /��/6// /�// TYPE OF ROOF COVERING
CDD&2ih �yj /� �� EXISTING
PHONE -�`�/ / ���" BUILT-UP ROOF
LICENSE ��y / ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed undo,provisions of Chapter 9(common
clop with Section 7000) of Division 3 of the emmess and Professions Code, WOOD SHINGLES
and my Imenea i) ri I force end enact
License Clap C/' Li<.Numbed. V � OTHER (SPECIFY)
Dots 2-Z'/-4 Connecfo. /F2_r-yv
OWNER-BUILDER DECLARATION
I h...by .farm that I am a..mp[ from he Contractor. Licenea LAW for PROPOSED
me following reason. (Sec. 7031.6. Business and Professions Code: Any city
unfy which requires a permit to construct altar improve, d.molish.or
npq,my structure, prior to it, issuance,Alt-regw [ sppliC.nl fo,.uch BUILT-UP ROOF
permit to flit a signed statement inet he a lican. punusn the provisions
of ms Contractor's License Lew (Chap ur 9 1 men<Ing wit anion 70001
of Division 3 of he Business end Professio oeel o.met n.It a or theca' ASPHALT SHINGLES
from and In. besis for the .Ileo. motion. Any violation Section V
7031.5 by shy applicant for n subject+ the Ikon[to a civ' enelty
of no[more mss five ..e aou..f Is500J. W.g . ole WOOD SHAKES
❑ 1,A.owner of ma propotY, or my am int
compensation, will d ma wo.x, one me *in .not i [ar�F1 I. d
for sale(Sac. 7044, B ineu and Pro'Msion TneCQQQQQQ 1r •s men WOOD SHINGLES
Law does not apply to
owno of prop 0 build. rPlovas[her n,
and who doss such work - sal o ro M1 own am rya "pro.ie In.,
such improvements ere not ' tend Tared for sled now , the OTHER (SPECIFY)
building or improvement is so wi ne veer^Y�[ urn tion, I owner
builder will have he burden of t t Fe eWrg1 build o prove for
purpose of sale.'. o l PROVIDE I.C.B.O. REPORT NO.
❑ 1, es owner of the proper[ em e c sively contrectin ith licensed
<omncfon [o construct the proja ISac. 7044, B..inass ❑ Pmf...I..,
coda: Tn.contr¢Io,. Licema Le doe.not pPly men a nor of Property PROVIDE MFG R. INSTALLATION SPECS.
who builds or improves [henun,and ho Contracts for s Project/with a
confractor(s7 licensed pursuant to the C t actor's Licen+
.a❑n 1 .m ...mol undo. se,. a.aP.C.for this APPLICATION DATE VALUATION PERMIT FEE
Own.. Data
WORKERS'COMPENSATION DECLARATION BUlldln
I hereby affirm that I have a certificate of content to self insure,o
Of.....of Work.,.Compensation Insu rent e,o,a certified copy[hereof ISac.
3800, Lab.CO. . 0 Sei$miD
Policy No. Company
BCertified copy is herefiled w that ie Cit Total
Certified copy is fled with tna city inspection division.
Applicant 0//�'
CERTIFICATE OF EXEMPTION FROM WORKERS. N D ❑ L ' IT AUTHORIZATION ♦ DATE
COM
PENB TIONmillet INS he NCE
par- ,Q C
I This cacti I nue not las Completed if the permit is for ossa hundred not r•1
LN wlaol o.less.) jiNp ■/�� /
I certify that in the performance of the Work to, which mit permit is
issued, 1 shell not employ any person In any manner so as to become subject
t0 ma WprkV� or Lew.of California.
Data AppliconI
NOTICE TO APPLICANT: If, off., making this Carlificate of Exemption,
you mould become subject to in*Workers' Compensation Provisions of the
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior toany roofing materielbeing
M.II be d.emed revoked.
I certify that I have read this application and t1.1.root the above Inform. Installed. If a roof Is Installed without first obtaining an
tion is correct. l agree to Comply Withall city and county ordinances dna inspection,I agrees moveall new materials for inspection
state laws relating to building construction, and hereby authorize rep,esen'
Olive.of this city to anter upon the above mentioned property for impaction '/
purpose..
IWtI aunts. sive, indemnifycosts and keep es which
the City of Cupertino
against sold City i corse sae,costs andthe expanses which they In any way eccrue
seainn uitl City in consequence of me granting of this permit. SIGNATUFrE OF AP ICA�� 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
SUBJECT: REROOFING POLICY FOR TIIE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
L Prior to permit issuance, you Must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first oblai,,ing all inspection and written approval
From the building inspector. A final inspection and approval shall be obtained from the building
inspector wile,, Ilia 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.
11) Prei,,speclion or tear off approval.
2.) lM progress inspcction approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor install;lioM
5. If plywood is installed,n plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be requircd to remove all new
material down to the sheathing and a building inspector will inspect all sluathiug at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH T11C
POLICY
I IOMEOWNERS NAME: "y� A[I
ADDRESS: ,�y
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RerooUwimvord