R-4033 (2) PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER R' 4033
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 OAYSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I BUILDING USE
RESIDENTIALX COMMERCIAL OTHER
OWNER'S ft VI *e_ ZL
HAZARDOUS ROOF
NAMEC' y AREA FIRE COLASS RING
154rq L.os lu to
ADDRESSI�.SQ�I^—•• in-. GO-L • �gM3Z — �7`t`f' EXISTING ROOF COVERING
PHONE O(� '• J J 3tOV NUMBER OF EXISTING COVERINGS
CONTRACT$ 1 1 ^ (\,
l,M�'1L-IAV^` �l.Gabti'Lf_ TO BE REMOVED� TO BE RETAINED
NAME 2D`n TYPE OF ROOF COVERING
ADDRESS 1 L.{l l �I�J�(,1��� EXISTING
CITY&ZIP Y/J/�—� �y,\
PHONE YJ t 1 ` I `) `- "JIG-q �—b� ASPHALT SHINGLES
BUILT-UP ROOF
LICENSE
NUMBER -2-10 I
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I nosey•tion that I am licensed upset a Bla.ion•of Chapter .fcoon' WOOD SHINGLES
and with Section Is I ]0001 of Division 3 of Me Btoinm and Professions
end nW Ca. I•i call P—;;
ttl Affect. 2r (t
Lion to — Lia Numbs. �Q
Date — conn«tor � OTHER (SPECIFY)
OlhWER BUILDER DECLARATION
I heresy affirm that I am exempt from the Contractor's License Law for PROPOSED
the following rascn. (Sec. 7031.6, Business and Professions Code: Any city
Or county which requires a permit to construct,slur, imprpye, damalish,or
repair any structure,prior to its issuance, also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
OI 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 Section
7031 by any applicant for a Permit subjects the applicant to a civil penalty
Of not more that five hundred dollen( 60OH: WOOD SHAKES
so I,a•owner of the property, or my employees with wages es their tole
cont pamolon, 'II do the work, and the structure is not intended or offered
tom ale (SK. )O,4e, Business and Professions Code: Th.Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who build{or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements a not Intended or offered for sale. If, however, the OTHER (SPECIFY) LI • I I Le— VUf I
bu ilei no or improvement is sold within one year of completion, the owner
builder will hve the burden of proving that he did not build Or improve for
purpose Of sale.). PROVIDE I.C.B.O. REPORT NO.
I, a owner of the property, ( irc. 7 44, contracting with licensed
ssions
cont: ton to
construct Me seLproject (Sec. Toa p Business and f Property Code The Contractor's Licenheroun and who cot.opts foenowner ojects with PROVIDE MFGR. INSTALLATION SPECS.
who aurin o eased pursuant
su nt to end who convacn for such Projects with ,
connKt am licensed under
Se to the Contractor's License Law.
reason I em exempt undo[ sea ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dat.
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to self-insure,or a car
tificate of Workers'compensation Ins ace,or articled copy thereof IS Seismic
3800, No. f.I rL�7 ' eoWDIR: emrn, `� ®D )�' .
Policy No. ih.,.b,zany l
fr''1� Peerfi Red copy is ne..bv mrnishee. J A^ TOtel
dCertif sed Kis til d wrt a ty in tlivision. R
Applicant��/{ th- (1
CER"151CATE E MPTION fRc M WORKERS' kf�� f TAU IDN DATE
N.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol �yuf'h
Tars($100)or Iso.)
I unify that in Me performance of the Work for which this permit I.
iuuad, 1 M•II not employ any person in any manner so as to become subj«t
to the Works s Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you Mould bK001. subj«t to the Workers Compensation provisions of the
Labor code. you must forthwith comply with Such provisions ons this permit All roofs shall be Inspected prlortoany roofing material being
Mall be dam.d revoked.
I cotify that I hay had this application and state that the some informs Installed If a roof is installed without first Obtaining an
tion is curt«t. I sora to comply with .II city and county ordinances and ,I agree t0 fem0 ball new mat r181S for IOSpeCt10R
state laws relating to building construction, and hereby authorize npresem
tatives of this city to anter upon the above mentioned property for insp«tion
aIWagru 1. save, indemnify and kap the City of Cupertino
against liabilities, nts,costs and es which may in any way"true
wimm said iyin consequence of the granting
of this Permit. SIGNATURE OF PLICANT 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
SUBJECT. REROOFING POLICY FOR 771E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNBT AND INSPECTION PHASE.
I. Prior to permit issuance, you "lust agree to co",ply will, U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied without first obtaining all hnspeclim, and written approval
from the building i"speclor. A final inspection and approval shall be obtained from the buildiug
inspector when elle reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. 1"order to receive a final,you "lust complete steps 1, 2, and 3.
l,) Preiuspeclion or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor i"stallatio"
5. If plywood is installed,a plywood "ail iuspection is required..
G. If any roof is applied without first obtaining mr inspection, you will be required to remove all new
material down to lire shentliiug and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOtv1L'OWNERS NANIE: h
a�
' ADDRESS: CLAP .
C-�
REROOFING COMPANY NAME: ✓ V
APPLICANTS SIGNATURE:
•
CITY OF CUPERTINO
BUILDING DEPARTMENT
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