R-4107 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4107
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM T ISSUANCE OR
IBD DAYS FROM LAST CALLED INSPECTION.
BUILDING AADDRESS BUILDING USE
/J
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARD
ROOF
NAME _ �( /yh FIREAHt: OUS COOVES ING
ADDRESS �eZIJ `� EG pL EXISTING ROOF COVERING
PHONE Z l —OS�4� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME l'L-C�wf/S YY/w� TO BE REMOVED �O BE RETAINED
c TYP OF ROOF COVERING
CITY&ZI 2 �/ 2 L-�NCd�iE/ app r XPi EXISTING
PHONE BUILT-UP ROOF
LICENSE G' J ASPHALT SHINGLES
NUMBER / e WOOD SHAKES -Z'C
LI LENSED CONTRACTORS DECLARATION
I
hereby Nlirm that 1 em licensed under provisions of Chapter 9(common
cin, with Section 70001 /y'v�yion 3 of the Business and Prof atslpna Lode. WOOD SHINGLES
and my license Is' II fes Yw Hect. is—�Fa-
DataLicense Clete Lit.Number J / %�
Date Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION p
I hereby affirm that I am exempt nom the Contractor's License Lew for PROPOSED
the following reason. (Sac. 7031.6, Business and Professions Code: Any city - ^
county which requires a permit to construct,alter, improve, damolish,Or I 4s
repair any rtructura,prior to in issuance, also requires me applicant for such BUILT-UP ROOF V
permit to Il la•signed statement that ne d licensed pursuant to the provisions
of me Contractor s License Law (Cnapnr 9 (commencing with Section 7000) Cpy
of Division 3 of In.Business and Professm
Professions Code)or that he 11.xep,them ASPHALT SHINGUU
from and the basis fpr the alleged exemption, Any violation of Section
7031.5 by any applicant for a permit`ubjects the applicant to a civil penalty V
of not more that five hundred dollen($600).1: WOOD SHAKES �C/Y/
❑ 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 or offered
Ig(.Sale (Sac. 7004, Business and Profession.Lode: Th.Contractor's License ODD SHINGLES
New gyes•not apply t0 an owner of property who builds improve+maroon,
S d-Impr o e mann work nit elfint or ed through o tris own rsole.employees,11, provided,that
ucn-linprovements are not intended o dueled for -le. It, nowavea the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
our will heva`me burden OI proving that see did not build or improve for
purP0se01 s.1..). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct m. project (Sec. 7004, Business and Professions
o .: Th a Contractor's Lice so Law does not apply to an owner of Property PROVIDE III INSTALLATION SPECS.
who builds or improves mareun, and who contracts for Such Projects With e
Contractor(.)licensed pursuant t0 the Contractor's License Law.
C] lam exempt antler set. ,BSP.c.for this eason APPLICATION DATE VALUATION PERMIT FEE
Owner De[a I
WORKERS'COMPENSATION DECLARATION Building
I haroby affirm that 1 have a certificate of consent to.ell�insun,or a car ��
Seismic
PDflcan of W.,kers Compensation Insurance,or a canities copy thereof(Sec
3800- .L.). /✓/1/y/
olityNo. Company
B Certified copy it hereby fur thenad. 6� Total
Certified copy is cinspectionh+io
lad with the city inspection disn.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section head not be completed if the permit is for one hundred EOI
nn($100)or Ira l '
1 certify enet in me performanceyperson
of any
work for which this permit is
issued. 1 Shall not employ any parson in any men er so as w become subject
to ma Workari Compensation Lem of California.n
DellApplicant
NOTICE TO APPLICANT: o alter making his Compensation
of Exemption,
YOU {M1Outl become Subject t0 ma Workers'COmOanaetion prOvi.iOna o1 the
Labor Coda, you must forthwith comply with such provision.or this permit All roofs shall be inspected prior to any roofing material being
anon be doomed revoked.
1 certify that I have rend this application and nate that the above informs Installs f a roof is installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspe IOflfr l agree tore see ell new materialsforinspection
atn• laws relating to building construction, and hereby outho rix. represm /
natives of this city to enter upon the above mentioned property for inspection /
pulp..... 6 z
(We) .gree fes siva, indemnify and keep narmlw ma City of Cupertino
against liabilities,judgments.costs and expenses Which may in any wase accrue
against Said City in consequence of the granting of this permit. l8i YAE F APPLICANT 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
SUBIECI': REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERIvllT AND INSPECTION PHASE.
L Prior to pencil issuance, you must agree to cowply with U.D.C. standards and utauuraciurers spec's
ou reroofing.
2. Ncry roof coverings slmll not be applied without first obtaining all inspection and written approval
front the building inspector. A final inspection and approval shall be obtained trout the building
inspector viten llte reroofing is completed.
3. All types or roof shall be inspected prior to any roof being installed.
4. In order to receive a rinal,you must complete steps 1,2, and 3.
l,) Preinspection or tear off approval.
2.)'yln progress inspection approval.
• 3.) Piiial inspection approval.
aJ k Operable smoke defector verificaliou
i b.) Spark arrestor installation
A.
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 sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY r,
HOMEOWNERS NAME:
2 28 PL
ADDADDRESS: /Z-
�
REROOFING COMPANY NAME: ✓�� H�g�s 5����'A�
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
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