R-4073 (2) PERMIT R� 4073
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITHIN IN DAYS ORMIT EXPIRES IF Fy ERMIORK T NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
--2oz�3
RESIDENTIAL COMMERCIAL OTHER
OWNER'S \^ ''".".yam t ,y
N • ` \d1f� FIRE HAZARDOUS COVERING ,}
NAME ���
�1 11 �� AREA CLASS
ADDRESS(, �577 � /0� � \N V EXISTING ROOF COVERING
PHONE (H 5 Z (.3 1 / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED 1 TO BE RETAINED
NAME ��� 1�C— "Roo�y 112 66 TYPE OF ROOF COVERING
DD
CIT a216 i�� �u�•TT1 EXISTING
PHONE T7I r –7 BUILT-UP ROOF
LICENSE !.� 5 0 ASPHALT SHINGLES
NUMBER 7('
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common
00WOOD SHINGLES
cin, with Section 701 of Division 3 of the Business and Professions Code,
and my
`license is ip-fuse and effect.
License Cb F Lia Number ��
Date ConbectorOTHER (SPECIFY)
OWNER-BUI LOER DECLARATION
I heteby .,firm that I am...mpt from the Contrector i License Lew for PROPOSED
the following reason, (SeC. 7031.5, Business and Profeaions Coda: Any city
or county which requires a permit m construct, alter, improve,demolish,or
repair any slmctute,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Perm it to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law Mhapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession.Corel or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mors that five hundred dollen MOO).): WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their sole
comp ens.,ion,will do the work, and the structure is not intended or offered WOOD SHINGLES c
for.ale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner Of property who builds or improves thereon.
and who OOe.Such work himself Or through his Own employee.,provided that
such improvement. are not intended or offered for sale. It, however, the OTHER (SPECIFY)
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
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
E] 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Cod.: The Contractors License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who<mtrecn for such projects with a
contraCtor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this
APPLICATION DATE VALUATION PERMIT FEE
Ow Date ry�1
her WORKERS'COMPENSATION DECLARATION P p B D Building
I hereby affirm that I have a certificate of c enI to self insure,or a car W
titian of Worked Com Den...ion Insurance.or en artif ted copv hereof(Sec. 000 seismic
3800,L.b,b.L„B-n GL ,} I
Policy No.CJ WAQ Company ✓TQ JUN 1 9 qct C Total
8 Certified copy is hereby furni /v7 y7
Cartifi y is filed wins me nap ti d' ;.I.,
A/
Applicant 4 L
CE IFICATE OF EXEMPTION FROM WORKERS' N.C. r COrPE MIT AUTHOR( DATE
COMPENSATION I N S URANCE
(This section need not be completed if the permit is for one hundred C10
I.L WWI or Itil l f
certify that in the performance person
of the work for a.lob this permit is 1L
Hwad, I shell not employ any parson in any manner so as to become subject
to the Workeri Compensation Lows of California.n
Date Applicant
NOTICE TO APPLICANT: If, after making in,. Certificate 0 Exemption,
Vo u should become subject t0 the Workers' Compensation provision.of the
Labor Code.you must forthwith comply with such provision,or this permit Allroofsshall be Inspected prior to any roofing materlalbeing
shall be deemed revoked.
1 certify that I have read this application and state that the above inform.. Installed If a roof Is Installed without first Obtaining an
upas is correct. I agr» tD comply with eat city and county ordinances and i cuon agree to remov I new m terialsfor sp ctlort
state laws relating to building construction, and hereby author i.. ..pr«em
,.lives of this city to anter upon the abovemenlmned property for Insoac on
purpose.. `., _ n /]
(We) agree to acus, indemnify and keep harmless the City of Cupertino !/I'lM1���/
against liabilities,judgments,costs and expanses which may in any was.,crate
awing said City in consequence of the granting of this permit. SIGNATURE OF APPLICANT ATE
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 TliE CTIY OF CUPERTINO BUILDING DEPART,IIENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you nmst agree to comply with U.B.C. standards and manufacturers spec's
ou 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. In order to receive a final,you must complete steps 1, 2, and 3.
1,) Preinspection or tear off approval.
2.) Iu progress inspcclion 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 mr inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all shcatltiug at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY 1
IIOMEOWNERSNAIv1E: �oc-yV "; O nT � �•�
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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