R-4114 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ran 4114
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 RMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS 1 BUILDING USE
1110 t ( ` - RESIDENTIAL—%_ COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME "�n & W 6Vaw
FIRE COVERING
AREA CLASS
ADDRESS f5aulyth�11) EXISTING ROOF COVERING
PHONE I&0
NUMBER OF EXISTING COVERINGS
CONTRACTOR'
TO SE REMOVED TO BE RETAINED
NAME I1 n� TYPE OF ROOF COVERING
CIITDY&iia 1 ` DC210— EXISTING
PHONE Zap--licog I Q5111 BUILT-UP ROOF
LICENSE ?n Z�Z� ASPHALT SHINGLES
NUMBER rev WOOD SHAKES x
LICENSED CONTRACTORS DECLARATION
1 hereby Affirm that 1 am licensednder provision,of Chapter 9(common
or, with Section 7000) of Division 3 of he eminm and Profession Code, WOOD SHINGLES
and mta.[
e .
Numb - AW
_
OTHER (SPECIFY)
WNER-BUILDER DECLARATION
hereby .felon that 1 am exempt from the Contractor's Code: Lew for PROPOSED
the I II.Win9 neon. (Ser. 7031.5, Business mtl Professions Coda: Any city
or county Which repui/a+ A permit 10 construct, .Iter, Improve, demolian,or
repair any structure,prior to its issuance,also requires the applicant for foto BUILT-UP ROOF
P
to file a signed statement that ere is licensed pursuant to I a provisions
of the Contractor's Liceme Law (Chapter 9 (commencing with S.clion 7000)
fromDivision 0 of the amines and..rrassiom Cotler or that he ti exempt there. ASPHALT SHINGLES
trim and the basis for [ere alleged of emotion. Any ant to.nevi Section
TOOLS by any applicant fora permit subjects the applicant to e civil penalty
of not mare[hat five hundred dry, (isy em WOOD SHAKES 3Ji'�V
❑ I, of owner o1 me pro work,
a o he emplpyan witM1 wend as[noir area
fon sale
will do me soak, end the structure i,not intended or License WOOD SHINGLES
La ole s n. 7 apply
Business and Professions who The Contractor's herema
Lew doer not apply [r a e/Of through
is o n employees,
to imp/Orel thereon,
and who does such work himselfint o.[Nod ger offered
own employees,provided[ort
such ng or improvement
are not intended or one
year
i f vale. It, however. the OTHER (SPECIFY)
building or improvement ip Iola within one year ri completion, the owner
builder will have [M1a burden of proving that he did not build Oa improvefr/
purpose o1fe1a'I' PROVIDE I.C.B.O. REPORT NO.
❑ I, ea owner 01 the Property, a exclusively contracting with licensed
Lontr.ctor: to construct the project (Sec. 7044, Business and Professions
ode: TheContrntor'fLicenseLowdoesnotapplytoanownero/property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve'menu.,.nd who contract,for such projects With e
contractor(')licensed pusu.nt t. he Contractor's License Lew.
❑ I am exempt under Sec. ,B.d P.C.10,this
APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERSCOMPENSATION DECLARATION T^` Building �,�2-QV
1 hereby affirm [hat I M1ava s certificate of consent to self insure,or DC7 p'� 1 !L�
testate of Workari Comp cation Inau.ence, tinea copy ma.aof(sec. �J �[ s Seismic /1 ay
0800 Lab. / nc /� (�d C_fYsy t / _✓
Policy NLrt,f�dL?, F►�5] ornpahy l'7V o/Lr a /,` pL
BG. bbd opv i+her.by lu rnishad. Total b-
certified copy I.fine win tea city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' NC ❑ PERMIT AUTHORIZATION DATE
COM PENSATION INSURANCE
(This section need not be completed if he perm,, is lo,one hundred dol. nn pp
Ar.(Si%or lesa.) r M I D� y
I certify that in the performance of the work for which [M1is permit i, J`
inued, 1 shall not employ soy person in any manner sr a.to become subject ^qq
to the Work.% Compensation Laws of California. Toe— AN70N
VIK
Data Applicant
NOTICE TO APPLICANT: If, eller making this Certificate of Exemption,
You should become subject to the Worker; Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit All roofs shall be inspeCQ14'1ttrtOAt*Ffl(?N IP material being
mall be deemed rwrkad.
I Ttify that 111.ye sed this application and state that the move informal (installed. If a roof is installed without first obtaining an
tion is orient. 1 agree m comply with all city and county ortlinances dna inspe on,I agree to re a all new materials for inspection.
state law' relating to building construction, end hereby authorize npraeem
tativn of this city to enter upon the above mentioned Property for impaction
PuaPOse..
IWt) spiv s. save, indemnify costs
and keep harmlesswhich themay
City of Cupertino
against II id City i judgments,ce of the expenses Which may In any way accrue
against said City in coneeouma of the granting of this Dermic SI A1'6Rr.PrAPP1 ICANT 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 DE2ART1vM'NT
PR10R TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you vast agree to comply will U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied %vilhout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained frour the building
inspector when the 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 nosh complete steps 1,2, and 3.
I,) Preinspectioir or tear off approval.
2.) Lr progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
G. If nuy roof is applied without first obtaining an inspection, you will be required to remove all ueiv
material down to the slicatliing and a building inspector Will inspect all sheathing at(fiat lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY �
HOMEOWNERS NAME: 1 q`o I rid 6uau -
ADDRESS: q n/ we 1q
REROOFING COMPANY NAME: Inc
APPLICANTS SIGNATURE:
III CITY OF CUPERTINO
BUILDING DEPARTMENT
Rcroof/wimeord