R-2136 PERMIT R_ 2136
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
'INITHIN180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS�sBUILDING USE
N Ile— RESIDENTIAL COMMERCIAL OTHER
OWNER'S
M / 1/ / I HAZARDOUS ROOF
NAME Qf" lh►2S '�iri•T I_C 1 L ( I ✓�✓L c+ FIRE COVERING
AREA CLASS
ADDRESS d `F `d•O G �el(!V i e�.'v i, .,L EXISTING ROOF COVERING
IVe
PHONE ^ e��Q (�i / NUMBER OF EXISTING COVERINGS /
- g/k J`. � ( �G '• iZ '/Z — '1,d 0 -
CONTRACTOR'S -
NAME '� � [ s TO BE REMOVED TO BE RETAINED
6 ^ UL TYPE OF ROOF COVERING ,
ADDRESS,
CITY&ZIP �/� 1�C�Aj MI91uLl WF u4 Sy 9S6�4re EXISTING
PHONEL`I 0.2 X13 p— �o �E �� - BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER
WOOD SHAKES l/
LICENSED CONTRACTORS DECLARATION
In,I W' S et!on that of lel.10d under a Bij.ions of d Pr.fi 9(commca,
and with enetmn wool of Dlnd.1f 3 m m. eu.ma..dna Pro+.esmn.cone, WOOD SHINGLES
end my liana Is In lull torte and,i+ecL '
Daen..Cite.. Lie.Numbs' - - - OTHER jSPECIFY)
Data Contrec[or
OWNER-BUILDER DECLARATION
hereby affirm that 1 em exempt from the Contractor's Code:, Lew for PROPOSED
the,here lug meson. (Sec. )0315, Business and ntract is Code: Any clry /SEC1
.1 county which r,0uire. 0 permit to construct, ,It.r„Improv,, a,mohm,or
repair any structure, prior to Its Issuance, also require,the applicant for B�4<- PROOF
permit to
file,signed statement that he is licensed pursuant to the provisions
OI [M1,Con t rector's License Lew IC hapten 9 (commencing with Se..ion 7W01
®
of Division 3 m m,Business and rend exlOes Dogiel or met.1 is a=erupt mer, LTSHINGLES
from and the besh for me ,(bred eXempts in Any ant t ion of penalty
of not by ethat live
re a Permit subjects OM1,applicant m,civil pmelry
of not more that+be ohne,,.donor.($s1 em D H ✓
❑ I, e.owner of the p.op,rly, o1 my employee,with wages es meh a Q(
.0mp.n satmn, will do the work, and the structure Is not Intend,.or m1, 117nOD$HI G S
/—� for wle (Sec. )D44, Busin,v entl Professions Code: The Contractor's Llcen ,U'
�—Lew doe.no[apply t0,n owner of property who builds Or improve.me.,on I V
and Who does such Work himself or through his own employees,provided m,
m 'mproysmen 1. are not Intended or offered for tele. 1+, however. he
THER,I5F�E IFY)
building or improvement i. ,old within one year of completion, the owner 1\ -
builder will have the burden of proving that he did not build or improv, for
Purpose01 a+sol„;;,, PROVII kC.B;O. REPORT NO.
❑ 1, a r st me pe project
t ( e:clo0”, contracting an Pr Ilwns . \
C°n Vac Th Contractor's c°mtrvct ice project (Sec. ,app B1.ano en r fproperty
pbul°m
code: Tneprove. hepon, andwhocnse Law does otepptsfoeuchPr ectswitha PROVIDE MFGR. INSTALLATION SPECS.
Who build. r Improves thereon, end wM10 contracts Ipl auto projec[a with e \
on7ractor(s)licensed pursuant 7o the Contractor's License Lew,
❑ I am exempt under Sec. ,B.GP,C.for his
eason FASTENER
Owner Data
WORKERS-COMPENSATION DECLARATION 1
I here., aunm that I have,certificate of consam 1.salt-Insi or a car TYPE •S•! x!-d /Q S
'Rican.of Worker,Compensation Insurance,or•certified copy thereof(Sec.
3000, Lab.C.).
Policy No: Company
8 Ceair,.copy Is hereby furnished. LENGTH
Ca.[I❑ed copy is filed with the clty inepecdon division.
Applicenn _ FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for on,hundred dol.
let.MIMI°`I°a'') VALUATI �
I cattily thrt In the Performance of me work for whi M1 this permit Is
Iva ed, I shell r��Ipppt employ any pen In
any me r s pc0 lett
tam eyllpfkTe-../�po pen Applicant
law Calle—for e.
One •//pp��TTYy Applicen'
NOTIC O ec me subject
It, el making 0M1B Cer[iticrte Ekemof the PERMIT FEEy �t
You
shOultl become mblett [o m Orkerf' Compensation p °t me
Labor Code, you,must forthwith c mply with such provisions o:�This permit DATE OF APPLICATION
shift be e,emed revoked.
I certify that I M1:ve I,ad this application and.1.1.that he above inform,.
tion is correct. I agree to comply with en city and county ordinances and I '
tate law, PhRIng to building construction, and hereby authorize r p.esen- /!v
t,tives of this city to enter upon the above mention"property 1°r Inspection b LL ll
purposes.
(We) agree to .aye, indemnify and keep harmless the City m Cupanho PERMIT VALIDATION
age' rt IlaGll isles,ludgmen.,c an ens eepenees which may in my w accrue O
aT said Clty pn..qu [n.gra p ow,'his perm) c 1-1 u 1990
ature of Appllcenucontraclb De�- 0
RE IRED PREVTNSPECTION . IN-PROCE S msndfibT4 FINAL INSPECTION
INSPECTIONS INSPECTOR DATE - INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
A Cites of Cupertino
10300 Torre Avenue P.O. Bo: 580
Cupertino,California 95014 Cupertino,California 95015
Telephone: (408) 252-4505
DEPARTMENT OF PLANNING AND DEVELOPMENT
SUBJECT: REROOFING POLICY FOR CITY OF CUPERTINO BUILDING DEPARTMENT PRIOR
TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to O=Ply with U.B.C.
standards and manufacturers spec's on reroofing.
2. New roof coverings shall not be applied without first obtaining an
inspection and written approval fran the building inspector. A final
inspection arra approval shall be obtained frau 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 CMIPlete steps 1, 2, arra 3.
1. Preinspection approval
2. Inprogress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
b. Spark arrestor installation
5. If any roof is applied without first obtaining an inspection, you will
remove all new material down to the sheathing and a building inspector
will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY ,[
HOMEOWNERS NAME: FA / Jr II/A r d
ADDRESS: / O D (e 7Vy �e 1. Lel
c �r
REROOFING COMPANY NAME: �J U 41 1`1 p oo �) /y q
APPLICANT'S SIGNATUREA.
CITY OF CUPERTINO
BUILDING DEPARTMERT