R-4008 (2) PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER R- 4008
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOF PERMIT ISSUANCE OR
IBD DAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDRESS R 1n - BUILDING USE
e� I,Jt-�!/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S ����//))��1Ippc����� O /-,,../�.n �j
W`-14�Ci1V0use L li—LJyw-5 F1 COVERING N�� COVVERING IS
NAME ' •t._' oV) L
�y 1 j n f AREA CLASS
ADDRESS- /'7�D/ �I�YLTl�I1/ ✓8 //e,�(1wc��L✓r EXISTING ROOF COVERING
PHONE vR - 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� �� .r TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS
TIEXISTING
BUILT-UP ROOF
PHONE / 1,6 P4_ -M-7
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I a li<mutl under provision•of Chapter B Icommao-
crag with Section TODD o14,isii 3 of me eosin«a an r 1. od., WOOD SHINGLES
and my"Co..i [tll Ind eHact.
Licenee CI • Lic.Number
Data = Convxtor ' OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Cunt...foi• License Lawfor PROPOSED
the following r.opn. (Sac. 7031.5, Busin.ss and Profession•Coda: Any city
Or county which requires a permit to construct, alter, improve,demoli+h,Or
repair any structure, Prior to its issuance,.1.0 nacelle.the applicant for such BUILT-UP ROOF
permit to fib a signed statement that he Is licensed pursuant to the provisions
Of me Contractors License Lew (Chapter 9 (commencing with Section 7000)
.1 Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the basis for the allao.d exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
01 not more that five hundred dollars(S500).): WOOD SHAKES q/�
❑ I,as owner of me property, or my employees with wages a their sole I0
compensation,will do,he work,and the structure is not intended or offered WOOD SHINGLES C�jY '2O
for sale (Sac. -7044, Business and Professions Code: The Contractor's License
Law deem not apply to an owner of property who builds or improves thereon, //}�[ so
and Yin 0 does such work himself or through his own employees,provided that
thatVF /�/1�
such improvements are not intended o offeree for sale. I1, however, ,be OTHER (SPECIFY) l�V
building or improvement is sole within one year of completion, the owner. O
build.,will have the burden of proving that he did not build or improve for
Purpose 011.1.1). PROVIDE I.C.B.O. REPORT NO.
❑ 1, s owner of the property, em exclusively contracting with licensed
contractor+ t0 c mtrucl the protect (Sec.,7044, Business and Plot...ion+
Cod.: In.Cc.1r.,or's Lic.na. Law doe not apply In an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builm or improve. thereon, and who contracts for such projects with a
contractorce
s)licend Pura...,to In.Contractor's License Law.
❑ 1 em exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner - Do,.
WORKERS'COMPENSATION DECLARATION 1 Building
I hereby affirm that I have a certificate... m consent to edit insure,ore<e..
tiliuh of yyorkam hatC.mphave a Imu o or a cel W rad eo insure,
of Isar. /7// Y// J` $eisffllC
3800,Leb. Q
Policy No. Company Pk �. y
Ceailiatl h nee. rue nail. Total
1p¢Cartif red e e city impaction division.
App-ITfn,^p^
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This.action need not be completed if the permit is for one hundred dole
len(5100)or laa.l Y
certify ho the, in theemploy
performance Person of the work for which this permit isIRtz J
use, 1 •hell not employ any Lenon in any manner so as to became subject
to the Workers'Compensation Lam of California.,
Date Applicant
NOTICE TO APPLICANT: If. after making this Ca titicate of Exemption.
You should become subject to the Workers' Compensation provisions of the
Labor Code, you mus, forthwith comply with such provisions or this permit All roof sh II insMd , ny roofing material beingshall be deemed revoked.Icatiry ,na 1 hey.sae mi.enpb=.apn ane.rat.....m..bpy.inrprm._ installed If roofthout first obtaining ention is correct. I agree [o comply with al city and county ordinances and inspectlo a mate
Inspection.
.1.1. laws relating to building c nstruction, and hereby autnorita r.pres•m
'ativa of this city to enter upon the above mentioned property for inspection
purpose..
(We) agree to save, indemnify and keep harmless the City of Cupertino
against n.biu,ies.judgments,cos,s and expenses which may in any way accrue
against said City in consaquence of the granting of this permit. §iGh 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
le,
SUBJECT: REROOFING POLICY FOR TILE CI1Y OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERfvUT AND INSPECTION PHASE.
1. Prior to permit issuance, you Must agree to comply with U.B.C. standards and manufacturers spec's
oM reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you Must complete steps 1, 2,and 3.
I,) Preinspectiou or tear olf approval.
2.) lir progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND TRE A13OVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY �✓O�i N4vsr� Peel/> -� pp
LIOWOWNERSNAME: ��/t/y �L'J/t9vS Com Ul !/b
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE: /
• C17Y OF CUPERTINO
BUILDING DEPARTMENT
Rercol/winword