R-4071 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4071
'
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT.228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESSBUILDING USE
�� / Z Q lI RESIDENTIAL `L COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE /fL\`{'^ ROOF
NAME N❑ L4�'-1 ` 1
AREA I "y CLASS COVERING A-
ADDRESS-' 1l oy&Dr /A� OrAVtDa r m w�J EXISTING ROOF COVERING
PHONE "7 �J -2 b NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CDD&Zsbp�5r3 5' � '�. EXISTING
PHONE / -- 75� C7 BUILT-UP ROOF
LICENSE � ASPHALT SHINGLES
NUMBER 4 to WOOD SHAKES X
L I CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licametl undo pr.vi+io[ts o1 Chapter 9(common
Ing with Section 7000) of Division 3 of the Business and Prof...lon.Code, WOOD SHINGLES
and my Ilcmu Is Infill co end aifecL �l C�P. lO
Lit.es.CI s G. Lit.Number "( J Lt.
Date Cornrwwr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Businessand Professions Code: Any city
or county which requires a permit to construct, alar, improve, demolish,or
repair any sVuclure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit t0 ill.a.ipnad.teament that he is licensed pursuant to the provisions
01 the Contractor's License Law (Chapter 9 (commencing with Section 7000)
' of Division 3 of the Business end Professions Code)or that he I...empt cher.- ASPHALT SHINGLES
from and ma basis for me alleged exemption. Any violation of Section
7031.5 by any applicant fors permitubjects the applicant to a civil penalty
oI not more met five hundred dollars($500). ): WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages as their sole
comp anution, ill do the work, and the structure is not intended or offered WOOD SHINGLES
for.ale(Sec. )044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property is o n am I. imp,OVM maroon, CIA
�
and wn0 dOee.cath work himself Or in to'
In M1i.Own amployaaa,provided that I/`l�/a_
such improvements are not intended . .fared for ..a. n, however, m. OTHER (SPECIFY)
uilding o improvement is sold within or
year of completion. me owner
builder will have the burden of proving that he did not build or improve for
purpose of set..). PROVIDE LC.B.O. REPORT NO.
C] 1, as Owner of the property, a exclusively contracting with licensed
contrac ton to construct the project (Sec. 7044, Business and Professions
Co.., The COmractor'sLicenseLawdoes not apply toanowner ofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves theraun, and who Contract+for Such projects with a
cont ractorls)licensed pursuant to the Contractor's License Lew.
ClI em exempt under Sac. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Date pp
WORKERS'COMPENSATION DECLARATION W 0 ® Building
I hereby allirm that 1 have a certificate of consent to self insure,or a car
tiiicate of Workers' Compensation Insurance, canitied co y thereof ISeC. /),e�� ,^ �/ c, O/� Seismic
3900,Lab. 17ft.7� Company .5 �- {/,1kfg />1J lT/ D 0
Firda
ICYNo. CII, 19g� Total
Certilied copy a hereby turn i shetl.
G.[il i•Q{opv n ti e m e cit a lion division.
Applicant 4� /.�v.
sal/
CE TIFICATE OF EXEMPTION FROM WORKERS' N C ❑ rKi,fyl1T AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section ..it not be completed it the permit is for one hundred dol
are
1 tify roar n mo performance of the work for which this permit is
hell
ISor loss.)
issued, I . not employ any person in any manner so as a become subject
to the W.rkeri Compensation Laws of California.
Date Applicant
NOTICE.TO APPLICANT: If, afar making this Canificate of Exemption,
you should become subject to the Worked' Compensation provisions of the
Labor Code,you must forthwith Comply with such provisions or this permit All roofs shell be Inspected prlortoany roofing material being
.hall be doomed r.voked.
I certify that I have read this application and state that the above inform. Installed. If a roof is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinanca.and ins ti n,I agree to remove all w materiala or inspe on.
state laws relating to building construction, and hereby Guth o rit. .,,..an
n
...ivof this city to onto,upon the above mentioned property for inspection
purposes.
IW ��
e) agree ro cave, indemnify end keep harmless IM City a Cupertino
.,.in liabilities,judgments,Costs and expanses which may in any way accrue
' .games hid City in consequence of the granting of this Permit. SIGNATURE 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
SUBIECI': REROOFING POLICY FOR TRE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to pencil issuance, you must agree to courply whir U.H.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied willroul first oblaiuing all inspection and written approval
From the building inspector. A final inspection and approval shall be obtained from lire building
inspector vvlren the reroofing is colupleted.
\\ 3. All types of roof shall be inspected prior to ally roof being installed.
4. In order to receive a final,you "lust complete steps 1, 2, and 3.
I,) Preinspectiou or tear off approval.
2.) In progress iuspcctiou approval
• 3.) Finaliuspecliou approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail iuspeclimr is required.
G. If ally roof is applied without first obtaining au inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at Ural Buie.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
IlOrArOWNERSNAME: 1 " rr�
ADDRESS: No�`D° i
REROOFING COMPANY NAME: 1�' ���
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword