R-4027 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 4027
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS OUILDING USE
IcAk pArag cl2ct,"fivir
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
�f rD TSM HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS EXISTING ROOF COVERING
PHONE Z �/ f NUMBER OF EXISTING COVERINGSC C
CONTRACTOR'S
'I� TO BE REMOVED TO BE RETAINED
NAME �T TYPE OF ROOF COVERING
CDDR$ZIP EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER
WOODSHAKES
LICENSED CONTRACTORS DECLARATION
I hereby cairns 00 I am licensed under provisions of Chapter s ons(Ccurinnuin
anD with .n tion 7full of Dlnd.11 3 or he eY.in...and Professions Code, WOOD SHINGLES
and my Ciensa b In full rOrce and a1Ln.
Cape Cie.- Lia Number
Dsa contrxro. OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
1 hereby affirm that l em exempt from the Contractors License Law for PROPOSED
the following raeson. (Sec. 7031.5, Bu\Inao and Prof an ion.Coda: Any City
or county which rewires a permit to construct. °ho, improv,demoiim,or
pair any structure, prior to its issuance,al.. requires the applicant for wch BUILT-UP ROOF
permit to fila a signed statement that he a licensee pursuant to the provifi ane
of the sione3 of the License Lew (Chapter 9 Code)(commencing that wins Section there If
of Division 3 of the Business the
and P.d exemption.
tion. or that of is exempt Section
ASPHALT SHINGLES
bons and
an basis ins me ellermi asampts the
Any ant to
of Section III
7031.6 by any t five hu re a Permit subjects ma•pplicen,io a civil penalty
of 0 more that rye In.pro Boum Issy em WOOD SHAKES ^
❑ L as owner of me work, a or he employees with wage.A. r Offered
r A
compensation,wise eL thesin work, and ess structure is not intendedntrto 's License WOOD SHINGLES D
for cal•(Sec. 7044, Business and Professions Code: The or improves
ors License
Low does not apply to an owner of property ebbe builtls or impr Ovef Inaraon,
and WDo does such work himself or through his own employees,provided that
such improvement. are not intended Lr offered for .ale. If, however, the OTHER (SPECIFY
builtling or improvement is fold within one year of completion, the ower. PR 14 WS
Guilder will have the burden of proving that he did not build or improve for
purpose Of'°'°I (SPROVIDE LC.B.�4YTREpOR T1NfO.
❑ 1. as owner of me property. am exclusively contracting with licensee VUr O
contractors to construct the project sec. 7044, Business and Profession+
Cod°: Til.Convector', License Law does not apply to an owner o+property PROVIDE MFGR. INSTALLATION SPECS.
who b.Ids
or improves thereon, and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law.
a.❑n .m exempt Yrd., sec. ,B.6P.c.for his APPLICATION DATE VALUATION PERMIT FEE
Owner self•
WORKERS'COMPENSATION DECLARATION Building r_ell
1 M1areby affirm that I nava i n Insurance.
of consent ie copelf y Cher o a car
3800, of Workers'Compensation Insu tante,o.a certified copy meteor(SOC. 1, Seismic l
3800-Lab.Cd. 17 1
Policy No. Company Y '
8 C.rtIII d copy is hereby th.the Cit Total
Cartifisa copy is Iltatl with Ina city inspection Olvifion.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.❑ PERMIT AUTHORIZATION DATE
COMPENSATION I N S URANCE1
(This section need not be com°lated it the permit is for one hundred tlol
Itr
Ins IS1001 or that
i
1 Certify mo m m• performance of the work for as toss this permit it ,;``••' (/,I 1� ) l
issued.
1 keel not amply any carton in any manner to°f to became subject
to the Workers'Compensation Lew.of California.
Dao Applicant
NOTICE should
APPLICANT: o afar making mea Compensation
provision.Exoff the
Vose mould Deco me st fort i ane Workari Compensation nshisa Int
Labor Code, you moat forthwith comply with such provisions or this permit
.hall b.deemed..yok.a. All roofs shall be inspected prior to any roofing materialbeing
I cotify that I have sad his application and fora met In.above informs. Installed If a roof is Installed without first obtaining an
,ion is correct. 1 agree to comply with all city end county ordinances and in action,I agree to remove all new material fore spection
at.0 laws relating to building construction, and hereby authorize sepr sen'
tnivef of this city to enter upon the above mentioned property for inspect on // �-�� .
pulp..... AMM /I a I Y ��
(Wal agree to Live, indemnify and kap harmless the City of Cupertino
against liabilities,judgments,costs and expenses which min
against said City in consequent°of the granting of this Permit.any wry accrue SIGN RE OFA LICANT 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
SUBJECf: REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you "lust agree to comply will' 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 lire building inspector. A final inspection and approval shall be obtained from the buildiug
inspector when lite reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4, 1"order to receive a final,you must complete steps 1,2, and 3.
I,) Prei"spectio t or[ear off approval.
2.) In progress inspcction approval.
3.) Final inspection approval.
n.) Operable smoke detector verification
b.) Spark arrestor installalio"
5. If plywood is installed,a plywood Bail inspcction is required.
G. If any roof is applied without first obtaining u' inspection, you will be required to remove all new
material down to the sl'calhing and a building inspector will inspect all sheathing al that time.
WE UNDERSTAND 771E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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