R-4084APPLICATION FOR CITY OF CUPERTINO
REROOF PERMITINSPECTION DIVISION
(408) 252-4505 EXT. 228
BUILDING ADDRESS r
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V fi%S RESIDENTIAI
OWNER'S
�� HAZARDOUS
NAME (� [--.1 FeRE.
ADDRESS \r� ' l
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NAME�OZLlo--
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PHONE 6,10\J g57/
LICENSED CONTRACTORS DECLARATION
I hereby affirm the, I am licensed under provisions of Chapvr 9 Icommm
eing With Section 7000) of Division 3 of the Business and Professions Coda,
nd my license in 11 I rc. and off c,. !� ,y—y
Ll came Clep Li.. Numbar/ -72./y'
Data Contractor
Niv OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Lew for
the following reason. (Sec. 7031.5, Buslnes. and Professions Coda: Any city
or county which requires a permit to construct, sitar, improve, demolalhor
repair any structure, prior t0 its issuance, also requires the applicant for such
Permit to fila a Signed statement that he is licensed pursuant to the provisions
o1 the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
of he
3 of the Business end Professions Code) or that he is exempt there
from and the basis for he alleged exemption. Any violation of Section
]031.6 by any applicant for a permit subjects the applicant to • civil penalty
o1 not more that five hundred dollars ($500).):
❑ 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
for .alis (Sea )044, Business and Professions Coda: The Contractor's License
Law don not apply to an owner of property who builds or improves thereon,
and who don such work himself or through his own employees, provided that
uchimprovements are not intended or offered for sale. If, however, the
building oimprovement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.).
❑ I. as owner of the property, am exclusively contracting with licensed
ontractorst0 c onstruct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Lew does not apply to an Owner o1 property
who builds or improves thereon, and who contracts for such projects with a
cont ractor(s) licensed pursuant t0 the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.AP. C, for this
reason
Owner Data
WORKERS'COMPENSATION DECLARATION
I hereby sl firmthat I have a certificate of consent to self insure, or s car
tificste of Workeri Compensation Insura�nce, .o,{r-a certified copy thereof (Sec.
3600, Lab. C.).
Policy No. Company
8 Certified copy i. hereby h��
rt
Ceilietl copy is filed withth the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. ❑
(This taction need not be completed if the permit is for one hundred doh
Ins 1110.) Or less.)
I CertilY [M1rt in the Performance Of the work for which this Permit is
issued, I mall not employ any person in any manner so n t0 become subject
to the Workers' Compensation Laws of California.
Dens Applicant
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption,
you should became subject to the Workers -Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit
.hall be deemed revoked.
1 certify that I have road suis application and state that the above informs
tion is correct. 1 age.. 10 comply with all city and county ordinances and
state laws raining to building construction, and hereby authorize represao-
...ives of this city to enter upon the above mentioned property for inspection
purpose'.
(We) age.. to Save, indemnify and keep harmless the City of Cupertino
against liabilities, Judgments. costs end expanses which may in any way accrue
against said City in consequence of the granting of this permit.
NUKE R- 4084
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING USE
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
f:T�:I�iUPI�a]
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
TO BE
WOOD SHINGLES p A 1 n
OTHER (SPECIFY)
PROPOSED
QTY �UrtHl U
BUILT-UP ROO
ASPHALT SHIN
ES
WOOD SHAKES
WOOD SHINGLES
l
OTHER (SPECIFY)
- /
PROVIDE I.C.B.O.
R PORT NO/
PROVIDE MFGR.
INSTA LATION SPECS.
APPLICATION DATE
VALUATION
PERMIT FEE
Building 9?'—
l/00,0,_
Seismic 45-0
MAY17 1995
Total 2�_"'o
J
All roofs shall be inspected prior to any roofing materiel being
installed. If a roof is installed without first obtaining an
inspection, l agree to remoye4il new materials for inspection
SIGNATURE OF 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
SUBJECT' REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR 7'0 ISSUANCE OF PERMIT AND INSPECTION PIIASE.
1. Prior to penuit issuance, you nlust agree to courply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. hr order to receive a final, you "lust 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 verificalio"
b.) Spark arrestor installation
5. Irplywood is installed, a plywood nail inspection is required.
G. If any roof is applied without first obtaining mr 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 T11C•
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
•
CITY OF CUPERTINO
BUILDING DEPARTMENT
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