R-4024 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4024
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 80 DAYS OF PERM T NOT
OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �� - BUILDING USE
2 l �J� Piz
RESIDENTIAL COMMERCIAL OTHER
OWNER'S JD
�/ - HAZARDOUS ROOF
NAME FIRE
COVERING
AREA CLASS
ADDRESS �Z��� !/C/✓'i�P_ �` EXISTING ROOF COVERING
PHONE �, ZS 3. zoG-
NUMBER OF EXISTING COVERINGS
CONTR��C/�OR'S� ,/�
NAME! �GC�f�/C /s-Oo��eCh�r//oq i e r TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CI TDR&Z10 L�� B r GC/ri � - EXISTING
PHONE .� � BUILT-UP ROOF
LICENSE - ASPHALT SHINGLES
NUMBER 6
WOOD SHAKE
LICENSED CONTRACTORS under DECLARATION
I herewith S affirm O ) of licence under a Business
of Chapter e s(coons Coat
ting with Section 1000)force and all a of m.epan....nd Professions coax, ODD GLES
and my Clsal I.In full force and aHam.
License Clap Lia Number
one Contractor OTHER (SPEC( Y)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Conbacto:s License Law for ROPOSED
the following reason. (Sec. 1031.5, Business and Professions Code: Any city
Or county which requires a permit t0 construct, altar, improve,demolish,Or
.pair env structure,prior to its issuance, also r°quirc the applicant 1°r such BUI T-LI F
permit 10 Ill.a signed statement that he is licensed pursuant to the provifi.ns
of the contractors License Lew (Chep[.,9 (commencing with Section]000)
of Division of me Business and Professions code)or met he d exempt there $P SH L
from and
Ina basis for the alleged ane mplion. Any violation of Section /�
7031.5 by any applicant for a permit subjects the applicant to a civil penalty `I
of not more that five hundred dollars( 500).1: W OD AKES
❑ I, as owner of the property,or my employees with wages as their sole
compensation,will do the work, and the structure is not intended o offered
for a.I.(Sec. 1094, Business and Professions code: The Contractor's License WO Q SHINGLES
Law whet not apply t0 an owner Of property who builds or improves thereon, , w� '
and uc who does such work himself int or through his own employees,provided that
such improvements, orpryare not old waw or one
year
for sale. If, however, m° OTHER (SP I
bulling or improvement is cid within p e hear OI of build
the owner
builder will have the burden of proving that he did not builtl Or improve for
Dprohae.�aale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, s owner Of the property, a exclusively contracting with licensed
con,rec,ors to construct the project (Sec. 1044, Business and Professions
Cod.: The Contractor's License Law does not apply to an owner of property pROVIDEMFGR. INSTALLATIONSPECS.
.no builds or improves tbereun, and who contracts for such projects with a
contrect°r(s)licensee pursuant to me Conbactor's License Law.
❑ am «+toot Ander sage ,B.&P.C.for this ppL(G� TIQ ATE VALUATION PERMIT FEE
own.. D.I. V
WORKERS'COMPENSATION DECLARATION n BuildinA �
I hereby affirm that nava i certificate . consent to felt in sore,ora seer R -
3800,°of Workers Compensation Insurance,or ancertified copy there.,!(Sac 7 'rn(�re Seismic \`
3800,Lab.C.). IJJVh
Policy No. Company '
8 CartiIled copy is Hereby in the CIt r Vf BUY Total
c..nn.e copy is fled wins mi ollr inweptmn wiwa1on. thIIN
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHO IZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for One hundred dot
I at Ita001 or less.) l
I tify t . in ma Performance of m• work for which this permit is
issue" I shell not employ any person in any mann er to as to become subject
to the Workers Compensation Laws Of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate o1 Exemption,
you should become subject to In.Workers Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit All roofs shall be inspected prlortoa y rooting material being
shall be tivm.d evoked.
I certify that I have read this application and state that the above informs Installe . If a roof Is Installed out first obtaining an
tion is correct, l agree t0 comply with all city and county ordinances and inspe f n,I agree to remove new materials for inspection
sun laws relating to building construction, and hereby authorize represem
utives of this city to enter upon the above-mentionee property for inspection
(We) agree t° save, ineamnifY and keep humlass tM Ciry of Cupertino �- v
.gains,liabilities,judgments,coats and expenses which may in any way.cc ru.
."im,aid city in consequence of the granting of this permit. SI NATURE/6F APPLI A T DAT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP, DAT 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 THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIORTO ISSUANCE OF PERNBT AND INSPECTION PHASE.
L Prior to penuit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
om reroofing.
2. New roof coverings shall not be applied willioul first obtaining all inspection and written approval
from lire building inspector. A final inspection and approval shall be obtained from lire building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. Ill order to receive a Gnat,you Must complete steps 1, 2, and 3.
1,) Preinspeclion or tear off approval.
2.) In progress inspcclion approval.
• 3.) Final imspeclion approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. if plywood is installed, a plywood nail inspcclion is required.
G. If ally roof is applied without first oblainimg all inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that live.
WE UNDERSTAND 111E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TM,
POLICY
IIOMEOWNERS NAME: /�// / //✓C/Z
ADDRESS:
REROOFING COMPANY NAME: /L �i�� ` �� �C ����09��✓
APPLICANTS SIGNATURE: excroi
• CI'IY OF CUPERTINO
BUILDING DEPARTMENT
RerooUrvimvord