R-4504 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4504
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �t
7 q0 /}HL- RESIDENTIAL_JK____:COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAMEroot assembly is required.
NO Initial I.C.B.O.M
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S 7
ffND�'f'�GKSTROM fECXS TROM ROpF/gVG' TO BE REMOVED 1 TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF COVERING
CITY 6 ZIP -1/p/3 ImRR/Se/✓/4✓e 0R/7 PBELL C'i/fF0o8_ EXISTING
PHONE 37D-167.5 BUILT-UP ROOF
LICENSE
NUMBER SB.Zys7 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' l+ - WOOD SHINGLES
C ❑
License Class 3 d9 Uc.Num
Date
��1g�COTHER(SPECIFY) ElOWNER BBUILDEUILDE
R DECLARATION PROPOSED
hereby affirm Bu that am exempt from s the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
con struct,altar,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
01 the Contractors License Law(Chapter g(commencing with Section 71 of Division 3 of the
. Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ -
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): .
I,as owner of the property,or my employees with wages as thelr sole compensation,will do WOOD.SHAKES ❑
the work,and the structure is not Intended or offered for eels(Sec.7044,Business and Profes.
sions Cade:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his Own employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he dirt OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PEWIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: G1 V ME
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, �T BW Idl �
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this e r
permit Is issued. 106 1 V 6�0 Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l�
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation Insurance carrier and Policy number are: 1, V x�MAQ Total
Carrier -5"1A7F fil Policy Na./lS.S668_1.T _%J ER tTAU1THORI N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ l
(This section need not be completed the permit Is for one hundred dollen(5100)Or less.)
I certify that In the performance of the work for which this permit is Issued, shall not employ
any person in any manner so as to become subject to the Workere compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,egor making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y p
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have road this application and state that the above information is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(We) purposes. fi/"/� ��/l/A�
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, 4LD C x�
judgments,costa and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT ATE
of the granting of Permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR TIM CITY OF CUPERTINO BUILDING DEPARTIVIENT
PRIOR TO ISSUANCE OF PERIvl1T AND INSPECTION PHASE.
1. Prior to pencil issumice, you nmst agree to comply with U.B.C. standards and manuf clurers spec's
Oil reroofing.
2. New roar coverings shall not be applied without first obtaining all inspection and written approval
Cram Une building inspector. A final inspection and approval shall be ebtnined from the building
inspector whenr Elie reroofing is conrplecd.
3. All types or roorshall be inspected prior to any roof being installed.
d. In order to receive a final,you"rust complete steps 1,2, and 3.
1 J Preinspcclioir or tear ofrapproval.
2.) 1"progress inspection approval.
3.) Final inspection approval.
• a.) Operable smoke detector veriF'catia"
bJ Spark arrestor iuslallatian
5. If plywood is installed, a plywood nail iilspcctio" is required.
6. If any roar is applied without first obtaining an irrspectian, you will be required to reprove nII "ev
material down to Ilia sheathing and a building inspector will inspect all sheathing at that lire.
WEND •R TAND TIIC• A13OVE POLICY ON I=.10GFING AND WILL COMPLY WITH THE
U C S
POLICY
110(viEOWNERSNAVIE: (%LhpyS KWOK -3333
y1s=967
ADDRESS: 74/0 5TENbA0V —
REROOFING COMPANY NAME: Er-k5mm 6,0 G c0
APPLICANTS SIGNATURE: �d P
I
CI'hf OF CUPERTIP 0
• BUILDING DEPARTNIL-Nl'
RercofA inaord