R-4085APPLICATION FOR
REROOF PERMIT
BUILDING ADDRESS /
Oto 9.75
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 252-4505 EXT. 228
NUMB R Roo 4085
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING USE
OWNER'S
r}— HAZARDOUS ROOF
1+'a14E'�^7 ��• IRE AJQ COVERING
NAME
Fn—.A rl Aee
ADDRESS
/OY i
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NAME � -� S�Satv+—S �mzD 1'��e-•tel
ADDRESS
CITU& S ?Si'ss� p q
PHONES S%Gi) 661 —//2
2.:�,Io s
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 (common
my with Section 7000) of Division 3 of the Businns and Professions Code,
and my license is 1 full a and effect. G
License Clan Lic. Number%�d p
Dau Contractor
OWNE BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
or county which requires a permit to construct, altar, improve, demorsh,or
repair any structure, prior to its issuance, also requires the applicant for such
Portait to Ill. • signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Codal or that he is exempt there
from and the basis for the alleged exemption. Any violation of Section
7031.5 by env applicant for a permit subjects the applicant to a civil penalty
of not more
that five hundred dollars ($500).):
❑ I'as owner of the property, or my employees with wages as their sole
compamatlon. Will do the work, and the structure is not intended or offered
for sole (Sac. 7044, Business and Professions Code: The Contractor's License
Law tlon not apply to an owner of property who builds or improves thereon,
and Who tlon such work himself Or through his own employees, provided that
each improvements era not intended oroffered for sole. If, however, the
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purposeof sale.l.
El I.
as owner of the property, em exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Coda: The Contractors License Law does not apply to an owner bf property
who builds or improves thereon, and who contra,, for such projects with e
contractor(s) licensed pursuant to the Contractor's License Lew,
❑ 1 am exempt under Sac. ,B.&P.C, for this
reason
Owner Data
WORKERS' COMPENSATION DECLARATION
I hereby affirmthat I have a certificate of consent to self insure, o a car
tificab of Work.Compensation Compensation Insurance, or a certified co y thereolc.
3e00 Lab. C,1. T_ T�
Policy No. Company �/��<G�
BCertified copy is hereby turnishatl.
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. ❑
(This section need not be completed if the permit is for one hundred dol
I.R. ($100) or len.(
I .stili, that in the performance of the work for which this permit is
issued, I shell not employ any person in any manner so as to become subject
to the Wcrkori Compensation Laws of California.
Dote Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Cod., you must forthwith comply with such provisions Or this permit
shall be deemed revoked.
Icertify that I have read this application and van that the above inform.
tion is correct. I agree to Comply with ell city and county ordinances and
state laws relating to building construction, and hereby authorize represen.
tetives of this city to enter upon the above mentioned property for impaction
purposes.
we) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, casts and expenses which may in any we, accrw
against said City in consequence of the granting of this permit.
ER
NUMBER OF EXISTING COVERINGS `
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF X
ASPHALT SHINGLES
WOOD SHAKES P I
WOOD SHINGLES MAY 17
OTHER (SPECIFY) 9
CITY OF UUPEK1INU
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
VALUATION
Building
/ yob - Seismic
7
RAA 1Y 1st r Total
I PERMIT AUTHORIZATION I DATE I
Jo,a
All roofs shall be inspected prlorto any roofing material being
installed. If a roof is Installed without first obtaining an
inspect( n, I agree to remo all new materials forinspection.
1 /C S—/7 -V
SIGNATURE OF APPLICANT DATE
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
0
SUBIECI': REROOFING POLICY FOR TIDE CITY OF CUPERTINO BUILDING DEPARTMENT
PIUOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to peruril issuance, you nmst agree to ca"ply 1vitil U.B.C. standards and manuracturers spec's
Oil 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 lire building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final, you "Lust complete steps 1, 2, and 3.
1;) Preinspeclion or tear off approval.
2.) In 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 any roof is applied without first obtaining an inspection, you will be required to remove all "civ
material down to lire sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND Tlir ABOVE POLICY ON IM- 1OOFING AND WILL COMPLY WITI1 TILE
POLICY
IIOlvtL'OWNERS NAIVE:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• Cl'IY OF CUPERTINO
BUILDING DEPARTMENT
Reroouwinword
�J
SUBJECT': REROOFING POLICY FOR 711E CUT OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
L Prior to penuit issuance, you must agree to cotrply with U.D.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings slrall not be applied %vilhout first obtaining all inspection and written approval
from [lie building inspector. A final inspection and approval shall be obtained front (lie building
inspector when [he reroofing is completed.
3. All types of roof slrall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1, 2, and 3.
I,) Preinspection or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable stroke detector verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspcctiou is required.
6. 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 771E A13OVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroot/wiuword