R-4401 (2) PERMIT R_ 4401 r
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
106 S9 RESIDENTIAL—)LCOMMERCIAL OTHER
OWNER'SHAZ
(i(/I/� 1 �I FIRE COVERING t1 \ COVVERING
ROOF
NAME N
AREA CLASS
ADDRESS EXISTING ROOF COVERING
PHONE 73
Z NUMBER OF EXISTING COVERINGS '
CONTRAC S f
D TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
!ADDRESS
/ Lys - y EXISTING
CITY&Zla !L R o , IGy ^Y/-/ ` V
ar.Gc v
' PHONE Tlao -7 BUILT-UP ROOF
ASPHALT SHINGLES
LICENSE NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 heresy etiont mat 1 am licensed poser provialom or Chapter B One coal WOOD SHINGLES P 4
Nnp with section 70001 or Division 3 of the Businan d Prol u om Coda,
and my Ilc•nee Isln roe ane.nett. g `
Llt.n.. OTHER (SPECIFY) R
Data Contractor
OWNER-BUILDER DECLARATIO
1 hereby affirm that I am exempt from the Contractor's License Law for PROPOSED C/IyU lI'
the Ipllowinq ruwn. (sac. ]0]1.5, Business end Profasfionf Coda: Any city h `�
or county which nauinf a permit to comtruct, alto, improve, demonh,pr UNk
repair any stluctura,prior to its issuance,also rwuir•f the applicant for Ruch BUILT-UP ROOF K1?lyo
oPillf
to aaipn waun menttheahe;alicensedencing it the tio7provisions0)
of the Contractor', License Law Professions
9 (commencing with exempt)0[101
from
Division 3 of the Business and..d ...m Code)or that he if exempt Section ASPHALT SHINGLES
Irom end the be.;a'for the allegad examms the
Any violation of Section
Of not o any t five
ichu re a permit subjects me °pplicam to a civil penehy
Of not sop.e that r of the property,
arty, r my em WOOD SHAKES
❑ 1, as owner of the property. or he employees with wend as Meir sob
compensation, x01 do the work,and the ens Co re is not intended 's offense
for fele (Sec. 7044, to neo and f Property
Code: TheContractor'smprove s License WOOD SHINGLES
Lew does not Ruch to m owner of property who n em to improves theProvided
that
Md who dose Ruin work not int or ed ., offered his own em11.. If,Prov teed m•1
spin improvements ere sot intended or neya br same If, nothevthe OTHER (SPECIFY) .,+--
build;nq or have the
bur is sole venin one year of ct build or the Owner.
buileer will neva tat°bwdan of proving that he did not build or improvefor
purpose of I.I.J. PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, em exclusively contracting with licensee
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor'aLicense Low does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
Who builds or improves thereon, and who contracts for such projects with is
con[ncaor(s)licensed pursuant to the Contractors License Law.
❑n I am exempt code. S.C. ,e.aP.c,for tote
rea APPLICATION DATE VALUATION PERMIT FEE
owns Da.
WORKERS'COMPENSATION DECLARATION pv Building`
� I hereby affirm that 1 have certificate of content to self insure,
or•cv� / 4y
t liceta o1 Workeri Co p s•pQn Insurance,or cenitiad copy t '2�1Z //f }[ f UO b $BISIf11C
0800,Lab.����ra y.����(JJ/�^ V/ Ora ✓( CC ( U
r Policy No.Ld a"f�./rr Company Lid-lA'Ls+
VC br:tl p p .wit 'shed. Total
�fCartifi/III a 1' d [ e ciW inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D PERMIT AUTHORIZATION DATE
COM P ENSATION I NS URANCE �^1
(This s•ceipn need not be completed if the permit is for one hundred dol I�
lets($100)or leu.)
I C°rtily that in the parfprmanca of ins Work for Which this permit if
issued, 1 shall not employ any person in any manner so as to become subject
to tba Workers'Compensation Laws of California.
Da- Applicant
NOTICE TO APPLICANT: 11, attar making his Car[ificateof E.hb,b.b. C1 �
Vow should become subject to he Workers' Compensation prov;sipm of the _e•F+
Labor Code. you most forthwith comply with Ruth provisions or this permit All roofsshall be inspected prior to any roofing material being
.Fall be deemed r.vokad.
I certify the' I have read this application and ante that the above informs. installed If a roof is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspect Bt0 r@ OVe all BW materl3lsf rinspection.
eon sew, his city t0 building n theconstruction.abovand ne pr authorize for
ranresam ✓ 9719
.1.1.a w this city[o ebur upon the mentioneddher by Guth for impaction (////
'propose.
(We) spree to a indemnify and keep harmless the City of Cupertino
against liabilities,judgments,coats and expanses which may In any way accrue
against said City in comenuence of me granting of this permit. $IGNA URE OF PPLICANT 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
i
SUBJECT: REROOFING POLICY FOR ThT CITY OF CUPERTI,10 BUILD ;G DEPA.RTNIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and rnanufac urea rec's
on reroofing.
2. New roof coverings shall not be applied thou[ first obtaining all inmec:ion and written approval
w
tion and approval shall be obtained from the building
from the building inspr_:or. A final inspec
inspector when the reroofing is completed.
r
3. All types of roof shallbe inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1, 2, and 3.
1,) P:einscection 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.
6. If any roof is applied without firs obtaining an inspection, you will be required to remove all ne.v
material dawn to the sheathing and a building inspector will inspe_:all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TnL
POLICY
HOMEOWNERS NAME:
ADDRESS:`.
1 ,965
t REROOFING COIvfPANY NAME:
a
APPLICA.`+'PS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTNIE NT
Rerooflwinwdrd