R-4031 (2) APPLICATION FOR PERMIT
CITY OF CUPERTINO NUMBER R-
4031
'
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITHIN 180 DAMIT EXPIRES IF WORK IS NOT STARTED
YS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
013 a/i kh ����
s- SIDENTIAL COMMERCIAL OTHER
OWNER'S U�Q Y'I'IAO V 1 e
/� v HAZARDOUS ROOF
NAMEAA ConpfQwl ZnC_. FIRE COVERING
15445 Los 0.{OS �fKl•� �+ Iki AREA CLASS
ADDRESS QI �C/_ os ISrA Q5,9 3 Z 254 4 EXISTING ROOF COVERING
PHONE O — :351c — 73 100 NUMBER OF EXISTING COVERINGS t
CONTRAC 'SQ
C, TO BE REMOVED TO BE RETAINED
NAME I o I,, ` C TYPE OF ROOF COVERING
crc�&is6 M� `�t —�— ✓ ,�� v�/]l�� 2 EXISTING
PHONE 'I � :L V )t� LLt. 40 BUILT-UP ROOF
LICENSE xxviiijt2//0 ��Io1 ASPHALT SHINGLES
NUMBER IvC /9 WOOD SHAKES !�
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision+of Chapter 9
cin.with Section 70001 of Division 3 of the Business and Proln{io�l�code, WOOD SHINGLES
and My Nc.np Is 111 f r 11_no f t. / O l
Do Obs$ IconNsct.r `C OTHER (SPECIFY)
DeLicn Contrxto.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lew PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coda: Any city
or county which requires a permit to c nstruct. alter, improve, demolim,or
repair env structure,prior to its issuance,also requires the applicant for Such BUILT-UP ROOF
permit to Ille 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 Code)or that he is exempt there ASPHALT SHINGLES
from and
the basis for the alleged exemption. Any violation of S.C[ian
7031.5 by any applicant for a punts[subjects the applicant to•civil penalty
or not
mo.•that live hundred dollars($500).): WOOD SHAKES
❑ I, as owner of the property,or my employees with wages as their sole
compensation,will do the work, and the structure is not intended o offered
for Sala ISec. 7044, Business and Professions Code: The Contractor I License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon,
and who don m
such work himself or through his own employees,Provided et
such lmpr°vements are not intended or offered for sale. 11, however, the OTHER (SPECIFY) LT.
building or improvement i sold within one year o1 completion, the Owner
builder will have the burden of proving that he did not build dr improve for
pulp...of Sao.). PROVIDE I.C.B.O. REPORT NO. 2P9 3
❑ I, as owner st me property, t ( exclusively contracting with licensedPROVIDE
ontre . as to Construct the project (Sac. nivel connect and Professions
contractors
ode: The Contractor's License Low does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds o improves thereon, and who contracts for such projects with e
contractors)licensed pursuant to the Contractor's License Lew.
❑ I em exempt under sea ,e.aP.c,for thisseason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION / ® Building
I hereby affirm that I have a certificate of consent to self insure,or a car
tificeI of Workers Compensation In • artif sed cop, Inera°I IS c SBISn11C
3300.Loll or a C'
Policy o. company a \yJ /tl.y�� NJ 199,5 10/2
��• Total
a;Ufietl copy h by 1 shed. V I
Cartifia opY filatl wit ancity inspection division,
ADp11UM C LI ILWd
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑ WIfT AUTHOR( DATE
COMPENSATION NSURANCE
(This section nod not be completed if the permit is far one hundred dol
or.(5100)or I...) ,
1 caanv den in the performance of the work for which this permit is
i+su ae, I +hall not employ any person in any manner to as to become subject
to the Workers Compensation L•ws Of Californian
Data Applicant
NOTICE TO APPLICANT: If, eftar making this Certificate of Exemption, Iff
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 shall belnspectedprlortoany roofing material bBin
Snell b•deemed revoked.
I certify that I have read this application and state that the above informs Installed. If a roof IS Installed without first obtaining an
ban is M role I .gr•• to ng con with .II city and county oris. cops end Ins ct n,lag ag a to remove I new materials for spect n.
{lit• law{ relating n building Cply with all and andherebyco auto price noes and
/(, /
tatives of this city to anter upon the above mentioned Property for inspection w
purposes. Y
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,cost+and expanses Which me,In any way accrue
egainst said City in consequence of mTU
e granting or this permit. S R F APPLICANT DATE
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
SUBJECI': REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
L Prior to permit issuance, you Must agree to comply will' U.B.C. standards and manufacturers spec's
on reroofing.
2. Ncw roof coverings shall riot be applied willnoul first oblaimirig all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from (lie building
inspector when lire reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
d. IM order to receive a final, you must complete Steps 1, 2, and 3.
1,) Preillspeclion or tear alt approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verificalioll
b.) Spark arrestor installation
5. If plywood is installed, a plywood Mail inspection is required.
G. If ally roof is applied without first oblaining aM inspection, you will be required to remove all Mew
material down to line sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND TIIE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOIAEOWNERS NArvIE:
ADDRESS:
REROOFING COMPANY NAME:
r
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroor/win ord