R-4155PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4155
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WRK IS NOT STARTED
ITHIN 1PERMIT 190 DAYS OXPIRES If F PERM T ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
N
OWNER'S
NAME
ADDRESS c�\a�% �— G S /.—LP
NAME
ADDRES
CITY & Zlh
PHONE'/�
S
LICENSED CONTRACTORS DECLARATION
1 M1araby ai/irm that I am licensed under provisions of Chapter 9 (common
cin. with Section )000) of Division 3 of the Business and Profesyione Coda,
and no, licenseand in I fort. affect. G
License Clap c"_ Lit. Number
Dat. Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 a exempt from the Contractors License Law for
the lollowin. anon. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or
repair any structure, prim to its is also requires the applicant fsuch
Permit to file a signed statement tim s licensed pursuant m the provisions
01 the Contractors License Law (Chapter 9 (commencing with Section )000)
al Division 3 of the Business and Professions Coda) or that he is exempt there
from and the basis for the alleged exemption. Any violation of Section
)031.5 by any applicant for a permit subjects the applicant to a civil penalty
of nmmon that five hundred dollars (5500).1:
❑ I, as owner of the property, or my employees with wages as their sale
tomp.mation'will do the work, and the structure b not intended or offered
for sale (Sec. )044, Business and Profession Code: The Contractors License
Lew does not apply to an owner of property who builds or Improves thereon,
and whodoes such work himself or through his own employees, provided that
such improvements are not intended or offered for sale. It, however, the
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.).
El I, a of the property, a xclusively contracting with licensed
connectors to construct the protect (Sec. 9044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property
who build$ or improves thereon, and who contracts for such projects with e
contractor(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec ,B.&P.C. I.r this
I eson
Owner Date
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to tl.imure, or a car
tifiuta of Workeri Compensation Insurance, or acertified copy thereof (Sac.
3800, Leb llI3755 11 /IUMtl
Policy No r Company _ed. C.
8 Certified Copy n hereby furnished.
Grtired y u filad.w t me city .patron dlvisin.
.Applicant ��—u �rrr� � v Liflyia'f /1Y�/i..
CERTIFICATE OF E EMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit is for one hundred dol
lots ($100) or Ins.)
I certify that in the performance of the work for which this permit Is
issued, I shall not employ any person any manner so as to became subject
to the Workeri Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after 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
analI be deemed revoked.
Icertify that I have road this application and state that the above informs
tion is correct. I agree to Comply with all city and county ordinances and
nate lows relating to building construction, and hereby authorize represen
Li ives of this city to enter upon the above-mentioned property for inspection
purposes.
we) agree to save, indemnify and bap harmless the City of Cupertino
against liabilities, judgments. costs and expense. which may in any way accrue
aWint said City in consequence of the granting at this permit.
HAZARDOUS
NUMBER OF EXISTING COVERINGS
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
ING
AINED
PROVIDE I.C.B.O. REPORT NO.
N
PROVIDE MFGR. INSTALLATION SPECS.
(APPLICATION DATEI VALUATION I PERMIT FEE I
—13 /o C) Total 1•9JI
PERMIT AUTHORIZATION DATE
I MR
All roofs shall be Inspected prior to any roofing material being
installed If a roof is installed without first obtaining an
inspectio/n/lg�gr/Q a�t�o remove all new materials for inspection
SIGNATURE OF APPLICANT DATE
I NRSE--INSPECTION: P. DATE NSP. DATE
DATE INSP,OGRESS: DATE I
TEAR OFF INSPECTION: BATTENS: FINAL
INSP. DATE I INSP. DATE INSP. DATE
I NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
SUBJECI': REROOFING POLICY FOR TRE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PER11UT AND INSPECTION PHASE.
1. Prior to peruhil issuance, you must agree to comply with U.B.C. standards and manufacturers spcc's
on 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 lire building
inspector wiles 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 "lust complete steps 1, 2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
r
aJ Operable smoke detector verificntio"
b.) Spark arrestor instnllntion
5. If plywood is installed, a plywuud "ail inspection is required.
G. IC any roof is applied without first obtaining an inspection, you will be required to remove nil new
material down to the sheathing and a building inspector Will inspect all,shcathing at (1131 lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COh1PLY WITII THE
POLICY
HOMEOWNERS NAIv1E:
ADDRESS: / S 9'
REROOFING COMPANY NA,NIE:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RercoUwiw.%ord