R-4076 (2) APPLICATION FOR PERMIT
CITY OF CUPERTINO NUMBER R- .4076
REROOF PERMIT INSPECTION DIVISION PER PERMIT EXPIRATION
4 WITHIN 10 DAYS OF PERMIT�ISSUANCE OR
( 08)252-4505 EXT. 228 IF WORK IS
18(1 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
r� Q BUILDING USE
D/7 7/—202-22- NOI4174�CAVe cJCJ RESIDENTIAL—L COMMERCIAL OTHER
OWNER'S HAZ1 _1{..,{
HOOF
NAME �� �py�T , l .O a FIRE COVERING
. / COVVERING A
(� AREA CLASS
ADDRESS- 1006,90 '' I\��T]Ir_�I�^ EXISTING ROOF COVERING
PHONE y15) a52 '- e.3 1- NUMBER OF EXISTING COVERINGS
CONTRACTOR'S cy� TO BE REMOVED TO BE RETAINED
NAME T�.� 1� RQ C& TYPE OF ROOF COVERING
ADDRECITY&Zlb I L�✓3 J 7 5T EXISTING
PHONE 7500 BUILT-UP ROOF
LICENSE /i� � ' O ASPHALT SHINGLES
NUMBER `T WOOD SHAKES !l
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision+of Chapter p Icommem
ing with Section 7000) of Divi.ion 3 Of the Business and Professions Coda, WOOD SHINGLES
and my license is jp fpl orce end affect, HS YJ v
Data I• G 3 Con Number
Data CorltratorOTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am...mot from the Connector's License Law for PROPOSED
the following reason. (Sat. 7031.8. Business and Prof anions Coda: Any city
or County which requires a permit to construct,altar. Improve, dem Olish,or
repel.any all.cmr..prior to in issuance,also requires the applicant for acre BUILT-UP ROOF
Permit to ma a signad statement mat he is licensed Punuent to the Provision.
of the Contractor'. License Law (Chapter 8 (commencing with Section 700D)
of Division 3 of the Business and Profession.Coda)of that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged a amption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant t0 a civil penalty
of not mor.that Nv.hundred doll..+( 500).): WOOD SHAKES
D 1, • ..he of the Property, 0,my em,l.y...with wap..as their sole
compensation,will do In.work, and the structure a not intended or offered
for u1.(Sac. 7044, Business and Profession.Code: Tree Contractor.License WOOD SHINGLES
andLow dhes not such to an owner r property who builds to i es, prov provided
that
end who does app, work himself or through his own employee.,Provided tont
such Improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) k
building or improvement is sold Within on• year of completion, the owner
builder will neve the burden of proving that he did not build or improve for
Pu
of sale,,. PROVIDE I.C.B.O. REPORT NO.
I, . owner of the property, a exclusively Contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build' or improve.
tneraun, and who contracts for such projects with a
contractor(S)licensed pursuant to the Contractor's License Law.
pI em ..amps undo. sac. ,B ala P.c.for this
roan APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that I have a certificate t consent to self.inwre,or c.,� 106
3800"of Workers'Compen+erion Imu.uyp,o.e card copy t araf IBa. 1•/ /�� �OJt\ $eI3mIC L
3800-Lab.G� 71�Company �Jis_4••t�C• TT��L� 4.•I `f
Policy No. 1.� f [' /
B
Certified appy i+hereby.lprni+n . . JUN 21 1995 Total
Certified tiled wrt the cU tliviuon, JUN
APPIIGOI
CER
,TilfhCATE OF EXEMPTION FROM WORKERS' CIIY Uh I' RMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N-C-�
(This section need not be completed if the permit is for one nuntlred dols
Par.IS 100)or les+.,
I certify the in tree performance of ms work for which this permit is
issued, I .hall not employ any parson In any manner so as to become s.bjal
to the Workeri Compensation Laws of California.
Del. Applicant
NOTICE TO APPLICANT: It, after missing this Certificate of Exemption,
you anould become subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this Permit All roofs shall be inspected prior to any roofing material being
shall be deemed revoked.
I certify met I have read this application and State that the above informa installed If a roof IS installed without first obtaining an
tion is correct. I .gree to comply with all city and county ordmences and Inspection,I agree to remove BW matefialSfO inspection.
Pure law. relating to building coninaOnon, and hereby authorize represem ��'I C�
tativas of this city to enter upon the above mentioned property for inspection (//
Purposes.we)
(Wal apse s, save, indemnity and keep harmless which the City of--- ---no
against liabilities,City i cons. see cons and expenses which mem in any way K<rue
awin+t said city.n pom.qu.npe of the granting of this p..mn. RE OF APPLICANT DAT
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
SUB1ECr: ItEltoOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIORTO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to pencil issuance, you Ilmst agree to comply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roar 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 [lie 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 Illus(courplele steps 1, 2, and 3.
1,) Preilrspeclioll or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verificalioll
b.) Spark arrestor installation
3. Ir plywood is installed,a plywood nail inspection is required.
G. If ally roof is applied without first obtaining all inspection, you will be required to remove all new
material down to the siteathiug and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME: ��ft�\�Ot�'^ � • O• ' `
ADDRESS: I O No M
REROOFING COMPANY NAME: a'r r el
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroor/wimvold