R-4035 (2) PERMIT 4035
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
Ol I�y�� • RESIDENTIALIL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME u FIRE COVER AREA CLASS ING
ADDRESS l `� Qxrlsk 2 `Qcga+ EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS I
PHONE
CONTRACTORy',5,, 1 l� TO BE REMOV ED--A- TO BE RETAINED
NAME S t`0-•101.1 � �INC 1 C'O TYPE OF ROOF COVERING
CITY&ZIP IRT$ lliP_ �oQAh1 �• Ml UIQ QSrJL13 EXISTING
PHONE I"I1 - °161--1 b89 BUILT-UP ROOF
LICENSE 1 �9 ASPHALT SHINGLES Y
NUMBER WOOD SHAKES `\
L I CENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 em licensee under provisions of Chapter B(Comm"
cine with Section 7000) of Division B of the Business and Professions Cod., WOOD SHINGLES
and my licensed force dna efb<c I I
License Lia Numbs
Data comrectn. OTHER (SPECIFY) m.
OWNER BUILDER DECLARATION W 4J
I hereby affirm that I am exam pe from the Contnct.P s License Law I., PROPOSED AU
the following reason. (Sec. 7031.5, Business and Professions Code: Any city /�
or county which requires a permit to construct,alter,improve, 0emolish,or G
repair any structure,prior to its issuance, also requires the applicant for such BUILT-UP ROOF 1 �99ry
Palm
it to file a signed statement that he is licensed pursuant to the provisions Coy G
of the Contractors License Law (Cnep.i.B (commencing Or trot with Section th... I from
Division 3 of Ta Business and Profusions Cone)or that he I.an.of S ehoP ASPHALT SHINGLES OLr-tk lie,
Irons end the applicant
for the alleged rmi exemption,the
Any ant to
of Section .v
of no by any applicant fora permit SOC).)s the applicant to a civil penalty
of not more that five hunthe pro dollars r my em WOOD SHAKES
❑ I,at owner of the progeny,a he employee with wends at Teff sole
compensation,will do the work, Profess structure Is not intendedntrtour offeree WOOD SHINGLES rev. Tile
for sale (Sec. TOaa, to an os and f propioni who
The Convector's License
Lew does not apply to an owner of property who miles or Impmvea Provided
that
and who doe such work nlmell Or through offered his Own Om.I.. If, howiver that ,
cat ng or temente are not i ld with o. neyfor .aims u, however,o er OTHER (SPECIFY)
l —Tp 1 .7I V1FL..
building or have the bur is Bole within one year of completion,rp owner
builder will have the burden of proving the he die not build or Improve for •'') /y��•�
Purpose O+P.I.J. PROVIDE I.C.B.O. REPORT NO. -09-S
❑ I, as owner of the property, em exclusively contracting with licensed
contractor, to construct the project (Sec. 7064, Business and Professions
Code: The Contractor's License Law does not apply toanowner olProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves ther.un, and who contracts for Such projects with e
contractor($)licensee pursuant to the Contractor's License Lew.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
ow Date
war WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to self insure, a car
tif00, Lo Workers'Compensation 1r, G,or a carti+iae c erao�lBec. •� 1 q a-. I $elamlC
3800- Leb. T JV1 J
PPlicy y�d4S SZ Campeny
u+i.a copy i hole lC. t ` I Total
c.rii}yq<o ejyL Alileew ecit ac non division.
Applicant \bel G]OlalL
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
(Thi,$action head not be completed it the permit is lot one hundred dol
lar$($I W)or Ie..)
Icanify that in the performance of the work for which this permit is
inuad, he not employ any parson in any manner to as to become subject
to the Work.,,Compensation Law.01 C.lifo,n.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You
should become subject to the Workers' Compensation provisions of the
Labor Cod., you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being
.hall be deemed revoked.
1 certify that I have read this application and state that the above informa Installed If a roof Is Installed without first obtaining an
lion is correct. I agree to Comply with as city and county oraln.n<es and Inspection,I agree to r neve all new materialsfor inspection.
nate laws relating to building construction, and hereby authorise teprnem
Utivo of this city to onto upon the above menti fined property for inspection ^ t
purpose.. CIT VA
. IWeI so," to love, indemnify and keep harmless fine City of Cupertino
against liabilities,judgments,cons and expenses which may in any wry accrue
against said City in consequence of Te granting of this permit. rArG ATUR OF APP NT 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 TIIE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to cottgily with U.B.C. standards and manufacturers spec's
ou reroofing.
2. New roof coverings shall not be applied without first obtaining all iuspection and written approval
from the building imspeclor. A final inspection and approval shall be obtained trout the building
inspector when lire reroofing is completed.
3. All types of roof shall be inspected prior to ally roof being installed.
4. In order to receive a final,you must complete steps 1, 2, and 3.
1,) Preinspecliou or tear off approval.
2.) lit progress inspection approval.
3.) Final iuspectiou approval.
• a.) Operable smoke detector verificaliom
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail iuspectiou is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to elle sheathing and a building inspector will inspect all sheathing at that little.
WE UNDERSTAND THE ABOVE POLICY ON IEROOFING AND WILL COMPLY Wall THE
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAIVIE:
J APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING
DEPARTMENT
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Reroof/winword