R-4074 (2) PERMIT Ree 4074
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS \ - c BUILDING USE
AO-5-33-` �O 5 I "OC`m4 '}6 �/J RESIDENTIAL COMMERCIAL OTHER
OWNENAME '1�`OS� �0�� 11 PLJ:r 1
HAZARDOUS ROOF
FIRE COVERING
CLASS
ADDRESS lomoNoc'�TV�Pa,Y1� L!-� EXISTING ROOF COVERING
PHONE q I �') a 5 Z - 6 3 ) NUMBER OF EXISTING COVERINGS
CONTRACTOR
``11 c� J TO BE REMOVEO .
(?&,,
TO BE RETAINED
NAME U`V`aK" KO �t7 4 c1 TYPE OF ROOF COVERING
RESS
CITY&ZIP 1853 S / J ry EXISTING
PHONE c?71 — 7SO Q BUILT-UP ROOF
LICENSE 45201,1 ASPHALT SHINGLES
NUMBER lJ x
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm 7000 I of Division
under a B..ma ai Chapter .IF on.Cod.,
and y license
section 70001 of Division 3 of 7000 ea.innpS5.md v.obasiom code, WOOD SHINGLES
and m s license i.�t^i ca.n0 affect "r
D... CI p Numbs. IIII"'' LlJ
Da. contrector ylOTHER (SPECIFY)
OWNERBUILDE R DECLARATION'
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.6, Butlnessand Professions Coda: Any city
Or county which requires a permit to construct, alter, improve, demolish,or
repair any structure, prior to its issuance, also requires the applicant for mcn BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
'
of Division 3 of the Business and Professions Coda)or that he is exempt more ASPHALT SHINGLES
from and the basis for me alleged exemption. Any violation of Section
7031.6 by any applicant for a permitubjects the applicant to a civil penalty
of not more that five hundred dollars 3500).): WOOD SHAKES
❑ I,as owner of the property,or my employee.with wages as their sole
compensation'will
Business end Professions Code: The Contractor's License ill do the work, and the structure is not Intended or offered WOOD SHINGLES
for sale(Sec.
Lew does not apply to an owner of property who builds or improves thereon,
and who does such
work himself or through his own employees,provided that
such improvements . not intended or offered for Bela. If, however, the OTHER (SPECIFY)
Ifiling or improvement is sold within one year of completion, the owner
builder will have the burden at proving that he did not build or improve for
purpose of..I.A. PROVIDE I.C.B.O. REPORT NO.
❑ I, a owner of the property, am exclusively contracting with licensed �,
cOmrac tors to construct the project (Sec. 7046, Business and Professions
ode: ThaContractor'aLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such projects with a
contractors)licensed pursuant 10 the Contractor's License Law.
reason .m .x.mpt under sap. ,e.mv.c.m.this APPLICATION DATE VALUATION PERMIT FEE
Owner oat. f—
WORKERS'COMPENSATION DECLARATION 9 A Builf:1 /
1 hereby affirm that I nava a certificate of consent to self insure,or a car
,rotate of Workers'Compensation Inau range,or p cartifie copy tne.pof Ise<. UAp 9Q �/7/c� 7��y $8lamlC On
3900.Lab.C.1_ 5 (t2t_1TC_ ,Y_w\I f�
PolicCeni Company
na.ebv furnished
Total
Cotifill is file wigrejoh.Cliff ilPatI,.n
division. (Jh
ApplicantG__L VUr
CE TIFIA CATS OF EXEMPTION FROM WORKERS' N C ❑ F NIIT AUTHORIZATI DATE
COMPENSATION N S URANCE
(This section need not be Completed it the permit is for One hundred dol
lora($100)Or less.)
I Cartily that in the performance of the Work for Which this permit is
....ad, I shell not employ any person in any manner to as to became subject
tothe Workers'Compensation Laws of Californ a. ISO
Dau Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Code.you must forthwith comply with such provisions or this permit All roofs shell be inspected prlorto any roofing material being
thall be deemed.evoked.
Icertify that 1 have read this application and state that the above Inform. installed If a roof is Installed without first obtaining an
tion i. correct. I agree to comply with all city and county ordinances and 10 tion,I agree to remove all new materials for Inspection.
.tete laws relating to building construction, and hereby autn Ori.a r.p,S..n
tetives of this city to enter upon the above mentioned property for inspection — /��
purposes.
(We) agree to .0 indemnify and keep harmless the City of Cupertino
.wins,liabilities,judgmente,costs and expenses which may in any way accrue
' against said City in consequence of the granting of this permit. A URE OF APPLICANT D E
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 TILE CITY OF CUPERTINO BUILDING DEPART,NIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PRASE.
L Prior to pennil issuance, you umst agree to comply will, U.H.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied willrout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when Ilse 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 roust complete steps 1,2, and 3.
1,) Preirispection or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verifrcaliou
b.) Spark arrestor iustallatiou
5. if plywood is installed, a plywood nail inspection is required.
G. Ir any roof is applied without first obtaining au ilrspeclion, you will be required to remove all ncry
material down to the sl,cailliug and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TIIE
POLICY
IIOIv1EOWNEi2S NAME: �a
ADDRESS:
REROOFING COMPANYNAME:
APPLICANTS SIGNATURE: T
Cl'IY OF CUPERTINO
• BUILDING DEPARTMENT
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