R-4117 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 4117 ,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
IWITHIN RAYS OF PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS J / BUILDING USE
Q Rd DENTIAL COMMERCIAL OTHER
O NER'S
HAZARDOUS ROOF
LAME /I1�1 I r`R Y..71_Q.l_. FIRE COVERING
1 AREA CLASS
A DRESS a 1 3� S.IRQn-b•PJI U (Ji,)CIN /�J/ XISTING ROOF COVERING
— fs<eN �- NUMBER OF EXISTING COVERINGS
f ONE
CCTRAC R'S
C TO BE REMOVED TO BE RETAINED
A E TYPE OF ROOF COVE ING
RESS
ITY 81 Zlb �p / Z� EXISTING
4/0NE DS' %?--6Q L/ 0Or BUILT-UP ROOF
LICK 3�� O ASPHALT SHINGLES SS
NUMBER WOOD SHAKES T
LICENSED CONTRACTORS DECLARATION
I hneby afllrm roar I em liunutl under provisions of Chepbr 9 Icommem
�no won s«emn T000l r Oroi.ion J of tat• aesin•n.ata P.of„Lion. coo., WOOD SHINGLES
and
my Ilc•nw b i fol i .ca era affam. O
Icmse less Lia Number
et• OTHER (SPECIFY) �'NPJLG.p n � v
OWNER-BUILDER DECLARA ON 04fiYUA N•f
following
titian met 1 . exempt nom sly ConnecmrY License Lew for V PROPOSED
of ounty iw reason. ices(Sepermit Business and Pltor, i pr Code: Any city
fop-it
county strict re, prior
t permit to construct,, also vires, improve, tlamolisn, h
repair any structure, prior io its issuance,h ei also reed to he provisions
r or wOh BUILT-UP ROOF
Permit to file t signed Li statemease Law that ata is licensed(commencing
pursuant it ma tion 7 00)
of theDiv Contractor's Business
Lew Itnepler Professions (commencing wim S«tion there
' fr Oivend J of the Bfor the ane gedexemption.
mConal or user he is n of S cAion ASPHALT SHINGLES
from end the basil for the alleged ata Pts th Any violation of S«tion
1031.6 by any spot ignl for a permi[wbjaco the applicant to a evil penalty
of nor mon that five hundred dollars(S500).1: WOOD SHAKES
❑ 1,a.owner of the property,or my employees with wages of their Sola
compensation,will do me work, and the structure is not intended o offered
for sale (Sec. 7044, Busin..y and Professions Coda: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and step does such w re nimnuored through offered
df r sets. ees, however,mat OTHER (SPECIFY( (///NPAriX L�,ID•
such improvements, 0rimprovare not old watl Or offered for cele. If,completion, thew the
building Or i ave�a bur ie Bold within One Ye di Of of builon ma owner
builder will neve me bustler of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
1, as owner of the property, am exclusively contracting with licensed
conn«tors to construct the Project (Sec. 7044, Business and Professions
Coda: Th0ContracmrsLicenaeLfwdoesnot apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves mer un,and who contracts for such projects with a
conn«tor(s)licensed pursuant to the Contractor's License Law.
ra•On I am exempt ender Sac ,S.aP.C.for his PPLICAT19 TE VALUATION PERMIT FEE
ow
Data
oar WORKERS'COMPENSATION DECLARATION Buildin
I hereby affirm that I have a certificate of consent to self-insure,o //��
�, tifiule of Workers Compensatiio/n Info ora certified copy thereof(Sac. IVA 1 Q �� //�� S813m IC
Jeoo.I•b' 3/2� m'6,. IST!A/ C /i9Ce , rev 'n/
Policy No P Y ry L (/ Total
.�Ca bfietl copy is M1eraby fernishatl. —��— Cif/ UI
f.. D Cgri iaa Coppyy'f rive m me city inspection division. L{/rC•Ll
Applicant /fY0a2. ...Com/ fl
C&—ANIFICATE OF EXEMPTION FROM WORKERS' N C ElPERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
len 131001 or lass.)
1 certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so es to become subject
t0:he Workers'Compensation Law,of California. •� �`
Dass Applicant
NOTICE TO APPLICANT: If, of tar making this Certificate of Exemption,
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 be inspected prior to any roofin n ter
shall be dsemed revoked.
I certify mat I have read this eppliutlon and flet.that me above informs Installed. If a roof IS Installed without first ob fling an
tion i,ws els I torn to ng coons with .11 city and county ordinances sand
Inspection,I agree to remove all new materials for inspection.
sole leof this
building auction, tined pr •eryfor represent
letives of mis ciW to enter upon the abovemmrioned property for inspection
purposes.
(We)l ague s, acus, indemnify costs
and keep harmless themay
City of--- ---i-- /Y/7�7
against liabilities,judgments.Cons Licots and expenses nt f this may in a waY«Gree / O
------
against said City in conwpuanu of the granting of this Permit $�ATU E OF APPLICANT OF APPLICANT � AT
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 ,
'L
• f
• i•i
SUBJECT: REROOFNG POLICY FOR THE CITY OF CUPERTINO BTjILDNG DEPARTMENT
PRIOR TO ISSUANCE OF PER2vaT AND INSPECTION PHASE.
,i
1. Prior to permit issuance you must ogre: to comply with U.H_C. s=dards and manuf-Ic-arc's spa's `k x
on remofing. i
2. New roof coverings shall not be applied without first obtaining all inspection and wrirea acproval
from the building inspector. A final inspe•jon 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 rr ve a final you muR complete steps 1,2, and 3:
3,) Preiaspecdoa or tar off approval
2,) In progress inspe:.ion approval —
3.) Final inspection approval
a) Operable smoke dere:or verification
7. +'
• fi b.) Spark arrestor installation
S. If plywood is installed,a plywood nail inspe%•tioa is required f {
' an mon, you will be required to remove all new
6. If any roof s applied without first obtaining insp
g i
material down to the sheathing and a buildinttspe=or will inspe x all sheathing at that time. {
WE UNDERSTAND Tr=. ABOVE POLICY ON RERROOFiNG AND WILL COMPLY WITH Tr= u +
POLICY r.I
HOMEOWNERS NAME:
ADDRESS:
i REROOFING COMPANYNAbIE:
APPLICAIN' 'S SIGNATURE:. .,
e
CITY OF CUPERTNO 1
BUILDING DE?ART:/MNT
f.'
Reroof/winward Y
,p ;