R-4023 (2) PERMIT o 4023
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 RMIT EXPIRES IF WORK IS NOT STARTED
VITTHIN ISO DAYS OF PERMT ISSUANCE OR
IW DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
H HAZARDOUS ROOF
NAME ' "O V�PO�n+ `O FIRE �J It) CLASS
COVERING A
AREA
ADDRESS 11�fs�0 Nalo;'f,-1- JLit EXISTING ROOF COVERING
PHONE 15 A62- 6:,319 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S —x--111
�Or y� ,f�,�Q CoTO BE REMOVED TO BE RETAINED
NAME ��O{`cy I `��-7CJT'. ` • TYPE OF ROOF COVERING
CITY&ZIP ' ` S• < +~ JEXISTING
PHONE 971 ' 7500 BUILT-UP ROOF
LICENSE �G�oio ASPHALT SHINGLES
NUMBER i.J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 tesedy affirmSection
that) am licensed unlet a Business
of d Profession.
9([.mode,
and y with s«npn 7000) of Division 3 of m. ap.m...and P.af...ian.cad., WOOD SHINGLES
and my Ilcmu b In II a dna efface 0
License A es co^N�ioet �I op OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I terse,affirm met I am...opt from the Contractor's License Lew for PROPOSED
the following r. (Sec. 7031.6, Business and Professions Code: Any city
or county which ��ouire$ a permit to construct,alter, improve, damalah,or i
repair any structure,prior to its issuance, also requires tneappliuntfareuCn BUILT-UP ROOF
permit to file a signed Statement that he is licensed pursuant to the provisi ons
of the Contractors License Law(Chapter 9 (commencing with Section 7000)
from
m Division 3 of the Business dna Proalleged
exem tion. or That he is mamas mese- ASPHALT SHINGLES
Irons and i3 breis for the alleged esions od Any violation ex of t ction
there
7031.5 by any applicant for a permitubjects the applicant t0 a civil penalty
of not more that five hundred dollars($5001 .1: WOOD SHAKES
❑ I,as owner of the property,or my employees with wages as their sole
Com Pensaticn, will do the work,and the structure is not intended or offered
I.'
"A (Sec. 70,44, Business and Profession$Code: The Contractor's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon,
andwtsale.no does wcn work himself or Through his own employ..,provided that +
tech improvements are not intended o offered for Ie. If, however, the OTHER (SPECIFY) 0.` L�>V�Q,
building or improvement i sold within one year of c mplelion, the owner
builder will have the burden of proving that he did not build or improve for
pulpa..ai Sale.). PROVIDE I.C.B.O. REPORT NO.
(:j I, H owner of the property, a exclusively contracting with licensed
cantractato construct The project (Sec. 7044, Business and Professions
n ode: TheCamractor'sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves tberegn, and who contracts for such project$with a
contral mr(O licensed pursuant to the Contractor's License Law.
❑n s m
am exempt andsap. ,asap.[.for i'
ria PPIBIC TI N DATE VALUATION PERMIT F E
Owner Date
WORKERS'COMPENSATION DECLARATION BUIIdI
1 hereby affirm that I have a Certificate Of consent 10 self insure,o
hfic.te of Work.,.' .n...ion lmu.ance.0,scoTried Copy In...of S.T. 4Y.�1 1995 �,��� Seismic
3800, Lab. if
Policy No. I Company ✓"^'e 1-7� /tl
Certified copy I.hereby furnished. {I U(: Total
8
car'
uisa� a W U I inspection division. UREHI'
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
L, PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This taction need not be completed i1 the permit is for one hundred tl01
Ian($100)or less.)
1 certify Lhet in me performance Of The work for Which this permit it 11
issued, I Shell not employ any person in any manner so as to become subject L`
to me Workers'Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, alter 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 mit permit All roofs shallbe Inspected pNort0any roofing material being
.nese be
a«sued revoked.
I certify that 1 have read this application and to,. he, he above informs installed. If a roof IS Installed without first obtaining an
tion is correct. I agree to comply With all city and county ordln.nces and in3peCtl n,I agree to remove all new materialsforinspection.
n.1. law. relating to building construction, and hereby auto Orin reDresm ^// rials)} 4`J
Pu ipH 01 this city to enter upon the above mentioned property for inspection 7
Dur we)
(Wal agree s, save, indemnify and keep harml.which ma City o1 Cupertino
against liabilities, consequence
coos and expenses which may In any way eccrYl NATURE OF APPLICANT DATE
against said City in cgnsdaumca Of LM1e granting of[M1i.permit.
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
SUBIEC'I': REROOFING POLICY FOR TILE C17'Y OF CUPERTINO BUILDING DEPARTMENT
PRIOR 7'0 ISSUANCE OF PERMIT AND INSPECTION PI LASE.
1. Prior to permit issuance, you must agree to comrply with U.B.C. staudards and manufacturers specs
om reroofing.
2. New roof coverings shall not be applied without first obaining all inspection and written approval
from lire building inspector. A final iuspection and approval shall be obtained from lire building
inspector when the reroofing is conrplctcd.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you Illus(comrplete steps 1, 2, and 3.
1,) Preinspeclion or tear off approval.
2.) In progress inspection approval.
• 3.) Final iuspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor imstallatiou
5. if plywood is fustailcd,a plywood uoil inspccliou is required.
G. If Illy roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all shcathiug at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY \
HOMEOWNERS NAME: N[9t iA OA
ADDRESS:
REROOFING COMPANY NAME: < c�104-
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Rcroof/winword