R-4040 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER R- 4040
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITHIN 180 DAMIT YS OF PERMIT ISSUIF WORK IS NOT STARTED
ANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
b2_-0 I I /. RESIDENTIAL COMMERCIAL OTHER
OWNER'S LVpt d -4-MSO I U
HAZARDOUS ROOF
NAME r FIRE A/0 COVERING
I V-5 �5 (.� 5 BI • IJ'// AREA CLASS
ADDRESSL9Cb-:e-,x''05 C�o-7. `9f5w32 '- Za` 4-., EXISTING ROOF COVERING
�PHONE dUQQ - �� ce O NUMBER OF EXISTING COVERINGS I
CONTRACTO
. /_ TO BE REMOVED TO BE RETAINED
NAME V I�-! TYPE OF ROOF COVERING
CDD arab EXISTING
PHONE ✓/ `" cii qq-0y, S BUILT-UP ROOF
LICEN (Q ( �q I 4c6- 6l-769 ASPHALT SHINGLES
NUMBEfffYYY��, Y
WOOD SHAKES r
LICENSED CONTRACTORS DECLARATION
I with S affirm 00 I of Division
tl under provisions o1 Chapter 9 Icommm"
my with s«alpn loom of Division 3 of he Bull....and Prof... n.cod., WOOD SHINGLES
and my license Is i uyc a fid Nfecl.
License Clea Lit.Number
Data - conn«mr�+ OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am...mpt film In.Conn«lOi• License Law to, PROPOSED
In.following reason. (Sec. 7031.5, Business and Profession.Code: Any city
Or county which requires a permit to construct, eILq Improve,d.-.1i.h,or
re°eany snm
ucn,prior to its Issuance, also requires the applicant for such BUILT
LT-UP ROOF
pero-mit to Ills a signed statement that he is licensed pursuant t0 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 I•exempt there" ASPHALT SHINGLES
from and the basis for the alleged examp[Ion. Any violation of Section
7031.6 by any applicant for a permit Objects the applicant 10 is civil penalty
Of not more that five hundred dollen($500).): WOOD SHAKES
❑ I,as..net of he property,or my employees with wages as Meir role
compensation,will do the work,and the structure is not intended or offered
for Ole (Be.. 7044, Business end Prof ession•Code: Tree Contractor's Liceme WOOD SHINGLES
Lew does not apply t0 an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that -� r
Such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) LIT I I IZ. " fa-
building or improvement is sold within one year o1 completion, the owner
builder will have the burden of proving that he did not build or improve for �J�
pur13
pose I. as PROVIDE I.C.B.O. REPORT NO. G
❑ I.
• r of ma property, am exclusively contracting with licensed
contractor. to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply tOanowner Ofproperty PROVIDE MFG R. INSTALLATION SPECS.
who builds or improves [hereon, and who contracts for Such project wi[n a
contractor(s)licemed pursuant 10 the Contractors License Law.
E31 am exempt under Sec. ,B.GP.C.for this
reason of Date PPLICATION DATE VALUATION PERMIT FEE
It W
WORKERS'COMPENSATION DECLARATION Building �SZ
I hereby elfirm that I have a certificate of consent to sell"insure,or a car
[iflcote of Workari Compensation In�p or reified c0�y m pf(6.F. 2419 �/ Q p Seismic It
3800,Lab c `Ln r. 1i`—( r_/},_ 'APR
SI
Policy No. tJ Ompany F'�Nkk✓���---WWW `YeLL.INI'L ls�r APR `-
rN etl troy If he' by furnished. Total
Can ifie p s f d wit it,6 a 'on division. YV .7` /�
Applieant �� �' C._— S s )F L;ul LHI INV
H
CERTIFICATE EXEMPTION F AOM WOR KEFIT NC
❑ PER UTHORIZATION DATE
COM NB millet INSURANCE
(This section nod not be completed it the permit if lest ossa hundred dol"
fers III D01 or Ies..l
I certify met m the performance of the work for which this permit iS
Issu ad, I shell not employ any person in any manner to to become subject
to[he Workers'Compenwtlon Law.of Calilornre�n
es
Dela Applicant
NOTICE TO APPLICANT: 11, alter making this Certificate of Exemption,
Vose Should become subject to me Workers' Compensation provisions of me
Labor Coda, you must forthwith comply with such provisions or this permit
Nell be deemed revoked. All roofs shall be Inspected prior toany roofing material being
I certify that I have read this application and stare that the ebox.Inform. installed If a roof Is installed without first obtaining an
,.On is Fort«t I agree m comply with all city and county ordinances and inspe lion,I agree to rem vea11 new m erials forinspection.
sod s of rel city o building n the above
and hereby aerty rose spresam
tatives of this city t0 enter upon the above"mentioned property for inspection / i _
purposes. / /q-,—r_7JI(1/��i��
(We) abree s, seve, indemnifycosts and keep es which
the City of Cupertino /`
ayein.t said City
i judgment,cents and expanses which they in any wry accrue
• awmn nm a[v in consequence of the granting of this permit SIGNATURE OF PL ANT 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 TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERrv1IT AND INSPECTION PRASE.
1. Prior to permit issuance, you umst agree to comply with U.H.C. standards and manufacturers spec's
oil reroofing.
2. New roof coverings shall not be applied without first oblaiuing all inspection and written approval
from lire building inspector. A final inspection and approval shall be obtained from the building
inspector when lite 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 urusl canrplete steps 1,2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspccliou approval.
3.) Filial inspection approval. •
a.) Operable smoke detector verification
b.) Spark arrestor iustallatiou
5. If plywood is installed,a plywood nail iuspecliou is required.
G. If any roof is applied without first obtaining au inspection, you will be required to remove all ucry
material down to 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
HOMEOWNERS NAME:
ADDRESS: `LO l S cne
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword