R-4140 (2) PERMIT R- 414 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408).?52-45@rsE7Ct. 228 PERMIT F I
EXPIRES WORK IS NOT STARTED
WITHIN IRO EXPIRES
FOF PERMIT ISSUANCE OR
-77-7-27-7e 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS / Tom// /BUILDING USE
S V lf�SSOa✓1 �2� RESIDENTIAL ✓/ COMMERCIAL OTHER
OWNER'S !� � • _ f
ROOF
NAMn�r,�G/� ��`� LrC.�/S� r/y FIREHAZCOVERING COVVERING
AREA CLASS
ADDRESS -7693 o/L,#,vG'e �Cos�'� D/!r_ .EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
t TO BE REMOVED TO BE RETAINED
NAME\IJ(AC;hP_1� - TYPE OF ROOF COVERING
CIITDY&ZIPRO- l3oxnn Monie 5ereg9D"I0 EXISTING -
PHONE 777- 833 t BUILT-UP ROOF
LICENSE / 7Z�2 ASPHALT SHINGLES
NUMBER 6 —1
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I hereWith S ction 7000 I of licensed under provisions of d Prof..(common
inq with Section 90001 .1 Division 3.t me eminan dna Profenions Coda, WOOD SHINGLES
ane my Cienu lyjn�iHo.<•ane atlam. -9 /'.2�
'2-
License Cbu !� '. `t Li<.Numbs `"[ OTHER (SPECIFY)
Data Contr«tor
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (sec. 7031.5, Business and Professions Code: Any city
county which requires a permit to construct, alter, improv,demoliah,or
r.P.ir any structure, prior to its issuance, also requires the applicant for.uch BUILT-UP ROOF
pomi to fila a signed statement that he is licensed pursuant to the provision+
of the Conti o the License Law (Chapter ei (commencing with exempt there
of Division 3 of basis
Bulinus and P.ofeesiom Code)or that he is not S there ASPHALT SHINGLES
from and ma ba+ia lar he anotia a mption. Any violation of Section
7031.5'by enV applicant for• arm rt F IecO Lh•spplicen7 t0 a civil panaliv
of not mora met fir•nonmed uen 1 Eli WOOD SHAKES
❑ 1,a' owner of no
pr ny,o my empmyees with wages es mai,sena
compensation,will do me k, e 1 atlucare is not inrended or offer.d WOOD SHINGLES
for Wa IS.<. B..in s ntl f Iona Cade: The con'ra<lor's license
Lew does not apaY to a her t p arty who builds or improves mer..n, Oyti obis-9�a
and woo does such work til or r u90 his own employees,provided mat /J
ao<n impr.v.m.nts .r. not d r offered for fill.. n, however, ma OTHER (SPECIFY) O/etroeAj e+{'
building or improvement a len - ane year of completion, Ina owner
bu it tler will have [M1e burden 1 being that he did not build or improv for
purpose ofsale.l. PROVIDE I.C.B.O. REPORT N0.
❑ I, as owner of In. roperty, . exclusively contracting wim.licansetl
contractors to construct the project (Sec. 7044, Business and Professions
Code: TheContr«tor. ucenseLowdoesnotapplytoanownatofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves tner•un, and who contracts for such projects with a
contractorO IContact pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this
r....n APPLICATION DATE VALUATION PERMIT FEE
Owner Dole
-
WORKERS'COMPENSATION DECLARATION Building $1• 6u
1 hereby affirm that 1 have a certificate of consent to self insure,or a car
tificata or Workers'Compensation Insurance,or a certified copy thereof(Sac. Seismic �_
3800,L.�
Poit5S5E gompeny
SC ACL fe Fl)Y1d
I icy L-
canis o v .In sur a Total Z�213
1rt+��1�1//IC 7i a s latl wi I t�insyytlon dlvlslon. Q ity,
Applicant - A iA v' .
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZ TION DATE
COMPENSATION N S URANCE 7 10
(This action need not be completed if the permit is for one hundred Cob 1V�5
Ian(5100)or Ins.) 1J 5
certify mal in the performance of [he work for which this permit is Cf(Y
issued, I shell not employ any parson in any manner so a.to become subject Vr L
to:he Workers'Compensation Laws of California.n UUrtnIIlVf r
Dots Applicant
NOTICE TO APPLICANT: If, alto making this Certificate of Exemption,
You should become subject to the Workeri Comb en9lion provisions o1 the
Labor Cod.,you must forthwith Comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being
shall be doomed revoked.
I certify that I have reed this eppliuti..and sten met the above informs Installed. If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with .0 City and county ordinances and inspection I agree to remove all new materials for inspection.
state law. meting t. building construction, and hereby authorize repnsen'
Otivaa of this city to mfr upon the above-mentioned property for Inspection
purpout
(Wel agree n. save, indemnify costs
and keep harmless the City of Cupertino
against liabilities,judgments,costs and expenses which may in any way«crus
against said city in consequence of ma granting of this permit. SIGNATURE OF APPLICANT DATE
(l PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP- DATE
TEAR OFF INSPECTION: BATTENS: FINAL
INSP. DATE INSP. DATE INSP. DATE
4S33o• NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
/z• y I r.,
C' -2
SUBIECI': REROOFING POLICY FOR 'IIID• CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to perurit issuance, you must agree to coruply willr U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied willroul first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector whe» llre reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
d. In order to receive a final,you must complete steps 1,2, and 3.
l,) Preinspeclion or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
S. If plywood is installed, a plywuod nail inspection is required.
G. Ir any roof is applied without first obtaining 'it inspection, you will be required to remove all new
material down to the slrcallring and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
II0Iv1EOWNERS NAbIE: %77,+; A
ADDRESS: 1 -768.3 O /L.
REROOFING COMPANY NA,VIE: Y)
APPLICANTS SIGNATURE: / Lzl —
Cl'1'Y OF CUPERTINO
BUILDING DEPARTMENT
Rereor/wimcord
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