R-4218 PERMIT
APPLICATION'FOR CITY OF CUPERTINO NUMBER R 4 218
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS • G� BUILDING USE
—5; - S RESIDENTIAL COMMERCIAL
OTHER 6110
OWNER'SHAZARROOF
1
NAME
/r U r'I / ��Iy 457/z I1 O 1 FIRE O CCOVERING
AKtADDRESS'2[,;�`SSS R0.1U Gh 4yL�X01?✓�` EXISTING ROOF COVERING
U
PHONE G [ f7 — ,� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME /t d O /"—/ 'y G TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS n �—
CITY&ZOO gg 7 •� l/� /nS��/ SC 71�� EXISTING '
PHONE 1/ / �O 1S BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
with
Section
7000 1 of licensed 3 of
a Business
of Chapter .(c.mman
ing with 9«tion 7000) or and affect.3 or the ea.in•...ata Prol...iom. cera., WOOD SHINGLES
License
my license is In full force and L
Data Cbu Lia Number
Da. Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contract.,'. Licence Lew for PROPOSED
The following reason. (Sec. 7031.5, Business and Professions Coca: Any city
01 county which requires a permit 10 construct, altar, improve. demolish,Or
,•pats any structure, prior to its issuance,also requires the applicant for such BUILT-UP ROOF
payofft to file a signed statement that he is licensed pursuant to the provisions
of tha Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business ane Professions Code)or that he is exempt there ASPHALT SHINGLES
4p from and the basis for the alleged exemption. Any violation OI Section
7031.5 by any applicant for a permitubjects the applicant to a civil penalty
or not mon that five hundred dollars 1$500) .): WOOD SHAKES
❑ I, a owner of the properly, or my employees with wages at their fol.
com panfation,will do the work, and the structure is not intended or offered
for Sale(Sea 7044, Business and Professions Code: The Connector's License WOOD SHINGLES
Lew don not apply to an owner of property who builds or improves thereon,
endwho does such work himself Or through his own employees,provided that t lGk'[vL�/Gti l c.
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
P.,
of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the properly. am exclusively contracting with licensed
connectors to c nstruct the project (Sec. 7044, Business and Professions
Code: The Contracto:sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or Improves theroun, and who contracts for such projects with a
connactorls)liicamsed pursuant to Te Connectors License Lew.
C3I am exempt .nae. sac. ,e.aP.c.for this
eason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that I have a artiticate of consent to self-insure,of a car,
tificete of Workers'C pen..Ii.n IOW r4ea�M�<a lifi�e '°°py thereof(Sec. �/ Seismic
Peer., L.b r 4 P' A I /. b 7
Policy N.. Company _�/��a� L"Alt/ . /•
I] Left cop n nenIt I fished. Total
J Cartiiiee filed wi ty 'on division.
Applicant _
CERTIFICATE OF EXEMPTION FROM WORKERS' RRPITittilkUTHORIZATION DATE
COMPENSATION INSURANCE N.C.
(This rection naatl not be completed it the permit is for One hundred dol
Ian($I W o.less.) �I
1 certify Shelf
that in the performance Person
er on of she work for which this ee subject is Ur LUr tr '
issued,
I Workers'
007 employ ion Laws
o in any mammal 30 as to become SUbjeCt il ek
to the WOrkari Compansetlon Lews of California.
Data Applicant
t,
NOTICE should
APPLICANT: o he W making this Certificate of Exemption,
you ,Cod brume subject i the comply
with
h suchCompprovisions
previsions o the
.hill edea,you must forthwith comply with tarn pr.yi.idn..r this permit All roofsshallbeinspected prior toany roofing materialbeing
T•II be deemed revoked.
1 certify that I have rend this application and state that the above informa Installed If a roof Is Installed without first obtaining an
tion is correct. 1 agree to comply with all city and county ordinances and Inspection,I agree to remove all new materials for inspection.
nate laws relating to building construction, and hereby suTorite rep,..n
tatyes of this city to enter upon the above mentioned property for inspection �//l 4
pur(We) /➢ /1�I SIO U !/ / I
(We) agree to siva, indemnify and bap nermins the City of i ..iUs LC—�I�Ur�'e
0wimt liabilities,judgments,costs and expenses which may in an seats accrw
against hid City in consequence of the granting of this Permit. SIGNATURE OF APPLICKNT 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
SUBIECf: REROOFING POLICY FOR TIIE Cl-i-Y OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manuf cturers spe.s
on reroofing.
J
2. New roof coverings shalt not be applied evithoul first obtaining all inspection and writlen approval
From the building inspector. A final inspection and approval shall be obtained from lire building
inspector when lite reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
d. In order to receive a final,you "lust comPlete steps 1,2, and 3.
l,) Preinspection or fear off approval.
2.) In progress inspection approval
3.) Final inspection approval.
• a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a piyrvuod nail inspection is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to lire shcailling and a building inspector will inspec-t all sheathing at [flat lime.
WE UNDERSTAND TILE ABOVII POLICY ON REROOFING AND WILL CONI-PLY WITH TILE
POLICY
1IONLEOWNERS NAME: �rl�/ !/!�/✓!/�, c✓� Ko li
ADDRESS: ZZ 37 � ��I/UCG�tD //liJfJ /yrCF�.
REROOFING CONLPANY NAME:
APPLICANTS SIGNATURE:
CLI,f OF CUPERTINO
• BUILDING DEPARTRI IT
RercorAvinword