R-1435 PERMIT R• 1435
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT
INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORKRK IS IS NOT STARTER
' WITHIN RAYS OF PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �� BUILDING USE
w
$I , RESIDENTIAL `I COMMERCIAL OTHER
OWNER'S �f� )
�� „^ 'w I`/ LSllue•-+�/
HAZARDOUS ROOF
NAME ,f
FIRE
COVERING JTL
Q� AREA CLASS
ADDRESS x � 2` ! D y-, r EXISTING ROOF COVERING
PHONE ��3 54/,q3 NUMBER OF EXIS�I\NG�COVERINGS
CONTRAC OR'S `�
TO BE REMOVED TO BE RETAINED
NAME — "/ X ,/�����., TYPE OF ROOF COVERING
ADDRESS
&ZIPC�rs/� zi_ l ['C A r r�v'�"'!"� EXISTING "�t�• ill
PHONE l�l BUILT-UP ROOF
LICENSE yZAfl ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm 1000 I of licensed 3 of t provisions ip Chapter 9(common
cine wins section 70001 of Division 3 of the Business na Profen' fie code. WOOD SHINGLES
end my IIcon se%tipLfll farce an effect. -A
Dates°CIigTR$ Contrractor `l// OTHER (SPECIFY)
11
OWNER.BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city q�p
recounty which requires a permit to construct, alter, improve,demolish,or PAID
pair any structure, prior to In Issuance,also requires the applicant for such BUILT-UP ROOF _
permit to file a signed statement that he If licensed pursuant to the provisions
nNOV
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) h� ^
• of Division 3 of the Business and Professions Code)or That he is exempt they. ASPHALT SHINGLES X
from and the basis for the alleged exemption. Any violation of Section'
7031.5 by any,applicant for a permit subjects the applicant to a civil penalty
of not more shot five hundred dollars($500),): WOOD SHAKES ---moi'-8f-�
❑ I,as owner of the property,or my employees with wages as their foie Vu(JWI 0
Com peril on,will do the work, and the structure is not intended or offered WOOD SH ING LES
Er sale (Sec. 7044, Business and Professions Code: The Contractor's License
Lew tloas not apply to an owner of property who build$or improves thereon,
and who does such work himself or through his own employees,provided that
uch Iso mmr
provees are not intended o offered for sale. If, however, the OTHER (SPECIFY) �Yw
building o. Improvement is sold within one year of completion, the owner
builder will have he burden of proving that he did not build or improve for
purpose of aid.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, s owner of [M1e property, am exclusively744, connecting with licensedsiori
Code: tan Contractor's construct the proles[ (Sec. ,app Bto an o entl Professions
Coaa: The improestherenseon,
Lowand doeswho cot°opts to an pr acts with
PROVIDE MFGR. INSTALLATION SPECS.
wno builds )licensed improves[horeo n, °fid who cpnnacn fore La projects wins a
ontrac am mptpursuant 10 the Connector's License Law.
❑ am exempt unser sac. ,B.&P.C.to.this FASTENER
. Ows Dat.
tier WORKERS'COMPENSATION DECLARATION � ��
I hereby affirm that I have a certificate of consent to self.insure,o TYPE
tificate of Workers' Compensation Insurance, certified copy roof(Sec. L
3800,Lab..fs�j..�,.�f�
Policy No. i�/]s/(]7�ij Company
corn ma���.�-��f!(.��^e��roby fund. LENGTH
Cenifie 1l�ld with the city inspection division.
Applicant FEE SUMMARY
CE RTIOF EXEMPTION FROM WORKERS'
COMPENSATIONmillet INSURANCE as
(This section need not be completed it the permit is for one hundred tlob �-
lan(euro) that
VALUATION _(/�/l/IU
certify that st the performance of the work for wM1ioM1 this permit is
Issued, I shell not employ any Lenon in any manner so as to became subject s
m the Workers'Compensation Laws of California. _i`-1VPI C
Dot
-.f J
De Applicanty O �J
NOTE TO APPLICANT: if s Iter making this Certificate of Exemption, PERMIT FEE
you should became subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
man bedeemud revoked. DATE OF APPLICATION
1 certify that I neve reed this application and nate that the above informs.
[ion is correct. I agree to Comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize remosem
hunts of this it,1p enter upon the above resell onad property for inflection
purposes.
(We) agree,to save, indnnnifY and keep harmless the City of Cupertino_ PERMIT VALIDATION
against lie dgme e�casts end expenses which sod's in any way accrue
against onwqut
ence of the granting of[hi Permit. ,
6� - 8r6
Sign ry c
aW re of pplicnnt/Contractor Data
REQUIRED PRE-INSPECTION IN-PROCESS YSPECTION FINAL INSPECTION
INSPECTIONINSPECTO DATE SPECTOR DATE NSPECTOR DATE 'N
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
a�
Cit4 of Cupertino
10300 Torre Avenue P.O. Box 580
Cupertino, California 95014 - Cupertino,California 95015
Telephone: (408) 252.4505
DEPARTMENT OF PLANNING AND DEVELOPMENT
SLWECr: REROOFING POLICY FOR CITY OF CUPEIiR'a10 BUILDING DEPAMMgT PRIOR
TO ISSUANCE OF PERMIT AND INSPE=ON PHASE.
1. Prior to permit iSSUanCe, you =St agree to 000Ply with U.B.C.
standards arra manufacturers spec's on reroofing.
2. New roof Coverings Shall not be applied without first dkaining an
inspection and written approval from the building inspector. A final
inspection and approval Shall be obtained from the building inspector
when the reroofing is Meted.
3. All types of roof shall be inspected prior to any roof being
installed.
4. In order to receive a final, YOU must CCMPlete steps 1, 2, and 3.
• 1. Prleinspection approval
2. Inprogrma inspection approval
3. Final inspections approval
a. Operable smoke detector verification
b. Spark arrestor installations
5. If any roof is applied without first obtaining an inspection, you will
remove all new material down to the sheathing and a building inspector
will inspect all sheathing at that time.
WE UNDERSIMM n1E ABOVE POLICY ON REROOFING AND WILL COMPLY WMH m
POLICY
H3KEOWNERS NAME: ;((`O� "(-I cn
ADDRESS:
REROOFING COMPANY NAME: '
APPLICANT'S SIGNATURE
CITY OF C[JPE mo
C� BUILDING DEPARIMERr