R-4019 (2) PERMIT R, 4019
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �,` BUILDING USE
0175 ` 2 NO 5�,Lxore RESIDENTIAL COMMERCIAL OTHER
OWNER'S
`r HAZARDOUS
ROOF
K at+A "T®�+ KOA FIRECOVERING
AREA �a
PCI,ADDRESS EXISTING ROOF COVER
ING
PHONE 2- 7
NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
— 1 r-,\NAME f O.,lair D '`fY.1 TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESSBIIP S 7 9�J(IZ EXISTING
PHONE
171 --75<2<!) BUILT-UP ROOF
LICENSE �5 O Q ASPHALT SHINGLES
NUMBER 7 WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
I hereby affirm Bot I em licensed under provisions of Chapter 9(comm an
Ling with Section 1000) of Division a of the Business•rd Prof ..Ions Cod., WOOD SHINGLES
and my liceffect, 11
License Cr"es �� c.Number N Z.0 I a
Dots �c
— Contractor OTHER (SPECIFY)
OWNED R-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor s License Law for PROPOSED
the to,
owing reason. (Sec. ]0]1.5, Business and Professions Code: Any city
of county which requires a permit to construct, sitar, improve, demolish,Lr
repair any structure,prior to its issuance, also requires the applic•ntfor such BUILT-UP ROOF
permit.to file a signed statement that he is licensed pursuant to the provisions
o+ the Contractors License Law (Chapter $ komm arrest wins Section t7000)
here
from
Divblon P m the Business and Staged
exams tion. or that he tion of
aeon ASPHALT SHINGLES
nom ate the basis for the •I l.,m. exemption. Any violation Lt Section
7031.5
o any t five +ora permit w0OH: one applicant to e civil Penalty
of not more that rivetheprhundred dollars r my em WOOD SHAKES
❑ I, ti ownsr of m°property,a o.he employees not wends d or oir.Ola
compensation,(Sec.
will e°thesin work,and the mucore is not Cora° 's License WOOD SHINGLES
for cafe (Sea 1 4.apply
Bmfines andnen f property
whtla: The Contractor's e's License
Lew eon not apply to an owner r property his
builds or i es. Ovef Provided
that
and who mdoes Such work not through Own employees.It, howiver,tthe
building
ng or improv are not old within n offered year thf ons n, nLthe o the OTHER (SPECIFY)
building il improvement the burden
sole within that
a year of completion,build or the owner
purpose
will nrva the burden of proving tM1et he eitl not build or improve for
ppnposa of sown PROVIDE I.C.B.O. REPORT NO.
❑ I, r' owner of the property,project ( ec. 70 4, Business a with licensed
oca: h.C C nsnuct the seLw Les 10x4, B10 naso and Profession'
ons
coo°: Tess or impcove'f License and who Co tapplyracts o an owner
Projects
is with a PROVIDE MFGR. INSTALLATION SPECS.
who builds or( Ol improves scant t, and sono actor'sLi fore Lo prolacta with °
conpe<t am licensed oder Se m one Contractor's License law.
reason 1 .m °"°mot came. sac. s.a P.C.los this APPLICATION DATE VALUATION PERMIT FEE
Owner Dna
WORKERS'COMPENSATION DECLARATION Buildin
I Mraby affirm Inn I have a certificate or consent to Sell.insufa,or a car T
tificat.of Worker.'Compensation Insurance,or a certified copy M1.'.of(Sec. 1� ' ® ,JO/O� Seismic
Policy Led.CI 71�I 'P+4''rS,)TC_ e�
Policy No. COTpanY
I] Car tifiad coo ian er°by fu.mshed. M Y 1 q Total
Certiliad y s filed with t <it pection division, d
AOPIicant�f4Aw/r}
CERTIrACATE OF EXEMPTION FROM WORKERS' N D ❑ Wily - ., _ A MIT AUTHORIZATION DATE
COMPENSATION INSURANCE url�
(This section need
hundred be completed if the permit is for one nunde aoL
are($1 bles )
1 c°nily that in the performance of the work for which this permit is Vag
issued, 1 shell not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California.
Data AppOc.nt
NOTICE TO APPLICANT: If, attar 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 roofsshall be inspected prior to any roofing materialbeing
shell be doomed revoked.
I certify met I have read this application and state that the above inform.- installed If a roof is installed without first obtaining an
pun is a.fr«t. I .g,. to comply with •u city and county ordinances and Inspection,I agree to remove all new materials for inspection.
non t nwrelating o building construction, and hereby aura Prize apreno-
natives of this city to annr upon the above mentioned property for inipoption 1� /b5(We) at,... to cave, indemnify and keep n•rmlou he City of Cuba"'"
against liabilities,judgments,cons and expenses which may In any way accrue
against said 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
SUBJECT: REROOFING POLICY FOR TILL CUT OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERIVUT AND INSPECTION PHASE.
L Prior to permit issuance, you ,just agree to comply with U.B.C. standards and manufacturers spec's
o, reroofing.
2. New roof coverings shall jot be applied witlsout first oblaining all inspection and written approval
from lire building inspector. A final inspection and approval shall be obtained from Ilse building
inspector wiles,the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. 111 order to receive a final,you ususl complete steps 1,2, and 3.
I,) Preiuspeclion or tear off approval.
2.) 111 progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood jail inspection is required.
G. rally roof is applied without first obtaining all inspection, you will be required to remove all jcw
material down to Ilse sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND TILE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY A
HOMEOWNERS NAME:
ADDRESS: s TO�gm— `O NoNN { G
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE: -14� 4
• CITY OF CUPERTINO
BUILDING DEPARTMENT
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I understand and comply tbitll Secliolt 1210-a of the Uniform IluYIng Code.
Section 1210-a rcQulllied when
mOLIMCdllor, lohe ccil ng,, single f orllwyallthcileach sleep uglroom and atCa
dcleclor will be insta
PAL
loses caoirnOy lcated 1, he
S11101ced dcotealtoos comply, no new detectors shill be rePhed.sleeping
• ll uudersland the above rupkement and cer ry that we now have sulolce Jelectas
iustallcd that do COMPIY.
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t understand and comply with Section 1210-a oC16e Unirorill Iluildill g Code.
ilin
Section 1210-11 IC(Pillcd vn c7tmlo2 its �he crl 'eil 1 Sligir ror11wa0WnlleachesleepJnglroom and it`n
detector will be insl
poi iosesltllrlexisolcug d ill til d 0.1ridect os cor 111 c , gi new deleclorosh,lhbc required sleeting
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•,. 1 understand the above rcguircmcnt and certify that we now have smoke detectors
inslfrllcd 01111 do comply.
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r.o,Box 500 ,
611Ciilna;CA 950150500'
.. 1010(1 lain Avenin
Cayci Ilno,.CA 75011.1255: , .•.
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1061 to 11001'251:4505 -
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I understand and colulily with Section 1210-a of Ilse Unifonu 13o11ding Code-
Section 1210-a reg111111edwn cnmtedlontthcI 1d11 nglr000, 'I'd atcn
detector will be insla
ioses1f exsleeting
oto
re
poi 111located
ill nqid.
molced Eeleclos couylly, o new detector
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•.. I uudersland the above requirement and cel fy that we now have smoke defectors
installed that do comply- N G�
AUDRLSS:
PLILMIT NUM.ULR: ---
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COMMUNrfy UEVGIorMENi -
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l understand and comply Will' Section 1210-n of the UI11rOrm 1luliding Code-
pp
Section IZ 10 l fcgil�lledcvn cnnlleldlls on lobe cij leil I Sic f orllw❑Ivill cich sleepJnglroom and ot(n
detector will be inst
poi to scs)tllflcxlocal slmokill ed dcle olecloos comply, 6o new delccloroshall lberreguired.slee(ing
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• L understand the about rcquircmail 'Jud certify that we now have smoke Jeleclors
lllslallcd that do conlPly-
7-02.0 s AlorA leti s are
ADDRESS:
400
1'L1tMITNUMI3ER:
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Cupci v.C1�05014.1255 -
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coMIv1UNITY otYr1orMENi
$MOICC.UG�'LC'!Ois CL'-IL'IIIICAfGOI COMI'LIAIJGE
I undcisland and comply with Scction 1210•a of the Uniform I3uildi19 Code.
Smo
Section 1210-n rcgulllledwluounllIcti led lon �he ecl i1 Sgle for11wynll ill
eich sleeprnSlroom and atcn
dcteclor Will be insta
point
cIItllfexl0elg d Impel d o"idos ()nlply, no new detecloroslo1i be regl+ired.sleCpl g
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•_ I undcrstnnd the pbovc regoircmonl nud crlify that we now have smoke detectors
incl 11cd that do comply.
ADDRESS:
prLItMIT NUM l3LR:
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?APR 21=1995 14 17 TAYLOR ROOFING 408 9711380 P.'01 , '
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CupCO1110,Cn 95015.0500
10,100 1n��r Avenue
' C.upnllno,CA 75011•)255 ,
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rAX: (jail)751.075)
COMMVN ITy.oCV@lormEN T '
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5MIZGUE'1'L• T it CL'R�1'll !CA'I E OP_.-_ _COMPLIANC—E
1 understand and comply will) Section 1210-a of the Uniform 13uilding Code.
ng
Section 1210 are Stalls lv"c unlledlon the single
ilWyj in eachesleepinglroom and atcn
dcteclor will be calelcc .
I>aili�tosesttlIflexisoting slin y maked detecltoor or area OVing access is cowPly, no new detectoroshall beUequired sleeping
• I I
I understand the above requirenlelll and certify that we now have smoke Jeleclors
installed that Jo comply. _
ADDRESS:
PL.IlMIT NUMBER:
hIOMrOWNlSRS SIGNA'1'URG:
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