R-4037OFFICE COPY
PERMIT 4037
R-
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT
IF PERMITISSUAOT TED CETOR
(408) 252-4505 EXT. 228 THIN ISD DAYS OF
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
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Por C 1^
" Y 64 I F � `�L-cf—,
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ Upei nO UI
C
HAZARDOUS ROOF
NAME r
FIRE C ING
AREA AID
LOS Z1105 11:511,11d.10
EXISTING ROOF COVERING
O
3�
ADDRESS
_73(608"
NUMBER OF EXISTING COVERINGS
PHONE V O
TO BE REMOVED TO BE RETAINED
CONTRAC'S /1
Il-�
NAME �Q
TYPE OF ROOF COVERING
CITY Zs , U r
EXISTING
/0
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES
-416 qbl 765
LICENSE`
n/
NUMBER
WOOD SHAKES
L I CENSED CONTRACTORS DECLARATION
I nenby affirm that I em licensed under provisions of Chapter 9 (Common
cin. with Section ]000) of Division 3 of the Business and Protest ppde,
WOOD SHINGLES
and mY If.... isi �u• a and effect.
License Cie. Lic. Numbar
Date contrxmr
OTHER (SPECIFY)
OW140rBUILDERCIECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for
PROPOSED
the 1011owing reason. (sec. 7031.5, Business and Professions Code: Any city
which requires a Permit to construct. Nur. Improve. demolish,or
recounty
pelr nenv structure, prior to in issuance, also requires the applicant for such
BUILT -UP ROOF
permit to Ilia a signed statement that helicensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (Commencing with Section )000)
of Division 3 of the Business and Profassiomi Code) or that he is exempt mere
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
)031.5 by any applicant for • permitubjects the applicant to a civil penalty
of not more that five hundred dollen (5500).1:
WOOD SHAKES
0 I, as owner of the property, or my employees with wages as their sole
Com pnnsetion, will do the work, and the structure is not intended or offered
to ..L (Sec, TOaa. Business and Professions Code: The Contractor s License
• WOOD SHINGLES
Law does not apply to an owner of Property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
uch improvements are not intended or offered for sola. It. however, the
OTHER (SPECIFY) L -f. 71 �2.-IJUP '1
building or improvement is 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 sal..).
PROVIDE I.C.B.O. REPORT NO.
I, es owner of the property, am exclusively convecting with licensed
Contactors to construct the project (Sec. TOfa, Business and Professions
Code: The Contractor's LlcenssLaw does not apply toanowner ofproperty
PROVIDE MFG R. INSTALLATION SPECS.
who builds or improves tbersun, and who convects for such projects with a
contractor($) licensed pursuant to the Contractors License Lew.
rch I em exempt under S.C. ,e.aP.D. for this
ea
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Data
WORKERS' COMPENSATION DECLARATION
is
Buildin4
hereby affirm that I have a certif icete o/ consent to self. insure, or a car.
PAID
tificau Ob Workers' tion In uratic qrA /iatl cony theraolFlcS c.
3800. Lab. 1IGGJJi' 111, V
Policy No. muff v
t((' R/
11,�^ �yh
$el$mIC ,1I_ r/�/��••/1
(3 Srprbhad copy s hereby furni+Pad.
arc., oDY is 'letl wk ata city i c ion division.
PR 24 199
Total
AOplic.m r
III
OF r'1 •PERMIT AUTHORIZATION
DATE
CER F EXEMPTION FROM WORKERS' N C ❑ kir
s
COM ENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol.
Ions ($100) or less.)
1 Certify that in the performance of the work for which this permit
issued, I shell not orany parson in any manner to n tobecome subject
to the Workeri Compensation Laws of California,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
All roofs shall be inspected prlortoany roofing material being
shall be deemed revoked.
installed If roof IS Installed without first obtaining an
I Certify that 1 have read this application and state that the above informs.
a
tion is correct. I tonge to comply with au city and county ordinances and
rr(///[[n11
lnsp Ionn, ln�to rr Ove all new aterlals for I pectl n.
ansa laws raledny to rap construction, end athpNze npresion
mentioned pr for inspection
mind upon the aboveep
tetivas of this city enter
Phe
purposes.
harmless Cit
Wife) agree to sew, ints.cots end bap harmless [fie City of Cupertino
save,
��
71 9
i id City i cons judgments. ceof and expanses which may in my wry attrue
against said
awth+t said ci:v th eonasqumpn of the granting of this permit.
SIGNATURE OVPPLICANT 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
0
SUBJECT': REROOFING POLICY FOR TIIE CITY OF CUPERTINO BUILDING DEPARTMENT
PP -10R TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to peruril issuance, you must agree to couhply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied willtout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be i"specled prior to any roof being installed.
A. In order to receive a final, you "lust complete steps 1, 2, and 3.
1,) Prei"spectio" or tear off approval.
2.) In progress inspcclion approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed, n plywood jail inspection is required.
G. If any roof is applied without first oblaini"g 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 lime.
WE UNDERSTAND "I'lIE ABOVE POLICY ON RL•ltOOFING AND WILL COMPLY WITH THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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