R 3926 CITY OF CUPERTINO
RECEIPT
No. 8/^481/0
DATE"CEI
FROM
VED
f-9r•1 Iri `
ADDRESS
' CASH CHECK NONEY
DOLLARS CENTS
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RECEIVED -
BY
02051`w Cp BUSINEMSYSTEW
1p15)MY]WS _
1
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 3926
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
2UY6`sj!jc l/\ r RESIDENTIAL � COMMERCIAL OTHER
OWNER'S
HAZHOOF
NAME —Arm 119 I
�� (�.W�l ./l�k F REARDOUS /^'� CLASS NG
AREA w CLASS
ADDRESS per'{!-/)✓�(`'• v' ` V I l EXISTING ROOF COVERING
PHONE 0 —v ` NUMBER OF EXISTING COVERINGS t
CONTRA TO
n TO BE REMOVED. TO BE RETAINED
NAME �6fcL /�, �/�,�� TYPE OF ROOF COVERING
CIITY&Zi ` V l.y /' EXISTING
O BUILT-UP ROOF
PHONE
LICENSE ry/ ASPHALT SHINGLES
NUMBER 1C C?
WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision.of Chapter 9(Common
crop with Section 7000) of Division 3 of the B.ninnf and Prof.ionf Code, WOOD SHINGLES
and my license is in full force and effect.
License Class- Lic.Number
nateCome.,., OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I h.n.by affirm that I am aX..Pl from the Contractor'. License Law for PROPOSED
the following reason. (Sec. 7031.8, Business and Professions Code: Any city
recounty which requires a permit to construct.alter. Improve,demolish,or
pair any fbucN.e,prior to its issuance, also requires the applicant for such BUILT-UP ROOF
permit to fib•signed.tutamen[that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (co 'ng wi th Section7000)
of Division 3 of Ma Business ands seri m ode)or to [ate'+exempt mare ASPHALT SHINGLES
Irons and the brei+ for fns all e..mption. Any solation of Sacti on
7031.8 by any appnunt for sort ubjactf the eppli[e t[o a l panel[.
of not more mat five nun d dollen(8500).1: WOOD SHAKES
❑ I,as owner of t property,01 '1n,cl.r.
mployee.winsMeir.ole
compensation, ill the work,enf pt Into ad or olfertlfor tale (Sec704Bnsine,send Pns Code:.Contrtrp;Licen. WOOD SHINGLES
Lew does not ly to on owns 1Y who b Idsor imp vas maroon,antl who so ch work M1imseN hie IOYees rovieetl fisth imprp ments a'. not int. n.. d noW.v.r, m• OTHER (SPECIFY)Guil'fnowor improvement is ; Y o Om igou,mM1e..no,
builder i have the burde ovi ng th nfPd� of Iltl prove lOr
purposeo sale.). PROVIDE I.C.B.O. REPORT N0.
❑ I,
Owner a ro arty. 99hI� ivelW/vla.t my With licensed
contrector to cons a proaj�rf){Sec. 7044, ass and Professions
code: me Dona. u[anseLe e,novtoenown..olproperw PROVIDEMFGR. INSTALLATIONSPECS.
who build. sup un no c O for ouch projects with a
comractorls)I ,erased p rs em to the Comr orY License Lew.
❑ I em ..a or un er Sec. ,B.&PCC.for this
ra.jrAPPLICATION DATE VALUATION PERMIT FEE
Owns. Otte
WORT RS•COMPE ATION DECLARATION p Building'
1 nanby Miens t i 1 nave ceInsuca[e of consent tad top,
o �'G `
['fico,o1 Workers'Co tion Insu ranca,ore<ertifietl copy thereof(Sec.
SBISmIC
OBOQ Lab.CO. \ k
POIlic7y No. Company
I] CertiOed copy is hereby furni+h.d. - 16198 t I)COO Total
Car[iflatl copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ UH -P RMIT AUTHORIZATION DATE
COMPENSATION N S URANCE fr
(This section need not be completed if the permit is for one hundred dol.
Int IS1%,C, esf.1 4.
1 certify that in me performance of the work for which this permit if (��Vf1J
issued, 1 shell not employ any person in any manner so as to become subject
to the Worker'Compensation Lew,of California.
Data AP011cant
NOTICE TO APPLICANT: It. after making this Certificate of Exemption,
you mould become subject t0 the Workers Compensation provisions of the
Labor Code, you must forthwith comply with Such provisions or this permit All roofsshall be Inspected prior to any roofing material being
.hall be deemed revoked.
1 Certify that I have read this application and state that the above informs Installed. If a roof is Installed without first obtaining an
lion is Correct. 1 agree to Comply with au city and county ordinances and inspection I agree to remove all ate materials for
inspection
state laws relating to building construction, and hereby authorize repeater.
,olives of this city to enter upon the above mentioned property for inspection
purpose+. /y
(We) agree to save, indemnify end keep harmless the City of Cupertino /fl 7
against liabilities,judgments,cons and expanses which may in any W-y--Crus YC
' against said City in consequence of me granting of this permit. IGNATURE OF AP CANT / DATE
PRE-INSPECTION: PLYWOOD: I N-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
0FFICE COPY
SUBJECT: REROOFING POLICY FOR 771E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you roust agree to comply with U.B.C. standards and manufacturers specs
oil reroofing.
2. New roof coverings shall not be applied without first obtaining all inspecliou and written approval
from lite building inspector. A final inspection and approval shall be obtaiired from the building
inspector wheu the reroofing is completed.
3. All types of roof shall be imspecled prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2,and 3.
1,) Preinspeclion or tear off approval.
2.) In progress inspecliou approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor imsiallaliou
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 lite slreallring and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TIIE
POLICY
IIOMEOWNERS NAME:
2
ADDRESS: 4
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RerooUwimvord