R-4083 APPLICATION FOR PERMIT R- 4083
CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 190 DAYS OF PERMIT ISSUANCE OR
• I80 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
c;L/ 33 -5 r2UmFa, p pit-, RESIDENTIAL COMMERCIAL OTHER
OWNER'S /
/J A HAZARDOUS ROOF
NAME L--�NA LE - FIRE COVERING
/� AREA CLASS
ADDRESS D/335 teN,f-oJ 10 EXISTING ROOF COVERING
S.0
PHONE NUMBER OF EXISTING COVERINGS 1
J l0
CONTRACTOR'S
NAME ���,-I�J P t i is TO BE REMovED YPE OF ROOF COVERING ED
ADDRESS
CITY&ZIP ' 3y 3-q 9odni(I]lesin QQ A c4 EXISTING
�[{
PHONE (rC�Jp 01$O BUILT-UP ROOF
LICENSE ,L ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provision.of Chapter 9(commem
.,no with Section TOOK) of Division 3 01 the Business and Professions Code. WOOD SHINGLES
and my StanIL,( ca and effect.
License Cis p Noor Lic.Number L
D.t. ContractorOTHER (SPECIFY)
OWNER-BUILDER DECLARA ION
1 heseby affirm that 1 am exempt from the Contractor'. License Lew for
the following ..Mn. (Sec. 7031.5, Business end Profession.Code: Any city PROPOSED
or county which req uires a Permit to construct, alter, improve, dam.lbh,ar
rapab any strucwto, prior to its issuance also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisl ons
of the Contractor's License Law(Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or mot he is exempt mate ASPHALT SHINGLES
from end the basis for the alleged exemption. Any violation of section
7031.5 by any applicant for a permitbjects the applicant to a Civil penalty
of not more that five hundred dollen($500).1: WOOD SHAKES
❑ I,as owner of the property,or my employs*$with wages as their sole
com palmation, will do the work,and the structure is not intended or offered
for eIe (Sec. 7044, Business and Profession.Code: The Contractor's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon,
and Wb0 does such work himself or through his own employees,provided that
buch improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
uilding or improvement is sold within o e year of c mpletion, the owner.
builder will have the burden of proving that he did not build or improve r
purpose.1sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I.
as owner of the property, a exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contrselo:sLicense Law does not apply toanowner ofproperty PROVIDE MFG R. INSTALLATION SPECS.
who builds Or improves manun, and who contracts for such projects with
ccmramor(s)licensed Pursuant to the Contractor's License Law.
C31 em exempt under Sac. ,B.&P.C.for this
r..son APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION W / ® Building
I hereby affirm that I have ceftific ate of consent to sell insure,or car
[iiicne of Wo'
ken'Compens r0n Insurance,or e c tifietl copy thereof(Sec. /J $e19R1YC
3800,Lab. n
� q. moan o c� y U Y� �J9tS 1� Total
Ql' Trued copy is by vie.
tified Cop y'
Appli ant
CG I E OF E) MPT10N FROM WORKERS' N.C. 0EIRMIT AUTHORIZATION DATE
OMPEN TION INSURANCE
(This• ti d nor b
tunneled
if ma permit is for one hundred dot
jars lS�I .r ess lG
I certify tort in t Performance of the work for which this permit is
issued, I sFsll not ploy any parson in any manner so p to become subject
to the Workers Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shall be deemed revoked. All roofsshell b I spatted prlortoany roofing material being
1 certify that I It...rend this application and state that the above informs installed I 8 OOf IS installed without first obtaining an
Lion is correct. I agree to comply with &11 city and county ordinances andiD3peCti I re r move all new materlelsfor inspection.
nate laws relating to building construction, and hereby authorise represeT
cativo Of this city to enter upon the above mentioned property for inspection
Purpose.
(We) agree to eye, indemnity and keep harmless the City of Cupertino
against liabilities,judgments,cops and expenses which e
against said City in con..gp.nce of me q..mmq of this p.�miL any way.vises $I OF LI NT
DATE
PRE-INSPECTION: PLYWOOD: I PROGRESS:
INSP. DATE INSP. DA NSP. 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
SUB1ECf: REROOFING POLICY FOR T'IIE CITY 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 manufacturers spec's
Oil reroofing.
2. New roof coverings shall mol be applied without first obtaining all inspection and written approval
from We building inspector. A final inspection and approval shall be obtained from the building
inspector wlhen the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. lit order to receive a final,you must complete steps 1, 2,and 3.
1,) Preinspeclion or tear off approval.
2.) lit progress inspection approval
• 3.) Final inspection approval.
a.) Operable smoke detector verificaliom
b.) Spark arrestor installation
5. If plywood is installed,a plywood 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 the shcathing and a building inspector will inspect all shcalhing at Wal Lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITII THE
POLICY L Alz�
HOMEOWNERS NAME:ADDRESS: 3U
REROOFING COMPANY NAME: �'l7Y;I
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RercofAvinword