R-4435 (2) PERMIT R_ 4435
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR'
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
LT�CDG /7 �/Qf�//U o� HAZARDOUS
ROOF
NAME FIRE
COVERING
/ !� AREA CLASS
ADDRESS_21a4/ if'I/'-�'I�DU EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
I �� �L /L/sJ /x1 TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS
CITY&zea EXISTING
PHONE
.W_ llGj_l0� ( BUILT-UP ROOF
LICENSE �g l�Z ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I witaby Section
that I of licensed under provision of Chapter s ons Code,
clop with s«non 70001 or Division 3 of the Business and Pro+aulom coda, WOOD SHINGLES
'�y and my Ilcanse' i II 1 zC.and select.
/ Lic.n..Coes Lic.Number />75/S—i- OTHER (SPECIFY) P I D
Oen Connector
OWNER-BUILDER DECLARATION
hereby
areas that 1 em exempt tram the d Pro error's License Lew for PROPOSED LIAR -7 {�EC'D
the
If
reason. (rest. permit, eu.ln st and Professions Impr Code: Any city
re county strict requires . permit to construct,alb,, Improv., demolisuch
repair any it a sign, prior to in issuance, also renin„the applicant to the provisions for sons BUILT-UP ROOF I(
permit to lo. .signsd ense Low thea her li(con poring[to the tion0) CI I T lir
of he sion 3 of the License Law(Chapter r 8 ode)or that with Section 7o001
'
from
Division 3 of the Business and alleged
ex ms tion. or that to Is exempt more ASPHALT SHINGLES / t
from antl the bops for the alleged exemption. Any violation of Section
1031.6 by any th applicant for permit subjects the applicant to a civil genas,
Of not mor1,as the rise the pro dollars my em WOOD SHAKES
❑ I,a i owner of me property,a or he employees withtenwages as[heir area
'or s to (Sec.
Will do sin work,and the structure is not intended License WOOD SHINGLES �
lar sola (fiat. 7044, Business and Professions Coda: The Contractor's license
Lew do.not spot, to en owner or property who build%or improves thereon,
and who don such work himself or through his own employees,provided that y
..ch Imp.oyamenn are not intended or offered for sole, n, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
build.,will have the burden of proving that he did not build or improve
purpose Of Sol..). PROVIDE I.C.8.0. REPORT NO.
❑ I. as owner of the property, a exclusively contracting with licensed
ontrsc ton to construct the project Icontractingsc. 044, Business and Professions
Code: Th0Contr«tor'sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who bu ilea or improves thenun,and who contracts for such projects With e
ontnctor(s)licensed pursuant b the Contractor's License Law.
p I .m exempt one., son. ,e.ay.c.for this
anon APPLICATION DATE VALUATION PERMIT FEE
own., Dat. q
WORKERS'COMPENSATION DECLARATION Building ad
I hereby affirm met 1 have a certificate of co t to self insure,or a car —/p •�7 11 Z� Ov
tifi � (�
cate of Workers' Insurance,or f �L
3800, Lab.
t Policy No:f�'']] �A
L Company � �. nieri copy thereof(Sec' Seismic
❑ Certified copy is hereby furnished. Total
O CeNliee copy is filed with ma city inspacnm dwiion.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This Section need not be completed if the permit is for one hundred dab
lar.($tool or Ion.)
1 Certify that in the performance of the work for which this permit is
issued. 1 .hell not employ any parson in any manner so as to become aubj«t
to the Workers'Compensation Lew.of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become sub)«, t0 the Workeri Compemnion provision. of the
Labor coda. you man forthwith comply with such provisions or this permit
shell be dawned revoked. All roofs shall be inspected prior to any roofing meterialbeing
1
certify that I have read this application and state that the above inform.. installed If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with all city and county ormn.n.e,and inspection,I agree to remove all new materials for Inspection.
net. lows relating to building construction, and hereby authorize represam
tetives of [hi.city to enter upon the above-mentioned property for inspection
purpose.. _.T— G •�7.
(We) .pre. to save, indemnify and keep harmless the City of Cupertino
notin.t li.bilities,judgmen.,cart.and expenses which may in any Way accrue
against said City in consequence of the granting of this permit. NATO E OF APPLICANT 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 THE CITY OF CUPERTINO BUII.DDG DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND L`ISPECTION PIi?SE.
1. Prior to permit issuance, you must agree to comply with U.B.C. stanaards and manufacturers rep's
on reroofing.
2. Nety 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.
1,) P.einspec ioa or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke dete^_tor verification
• b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required
6. 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 time.
E UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WTII? Tri
W
POLICY ' //
HOivtEOWNERS NAME: 4i, �cJ7yj�'/V
�
ADDRESS" :
REROOFING COMPANY NAVE: £
APPLICA`TS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTZ[ENT
•
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