R 1754 PERMIT R_ 1754
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION I I . PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
' -
WITH IN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION. '
BUILDING ADDRESS BUILDING USE
61 50 A u •I / - RESIDENTIAL 11�COMMERCIAL OTHER
OWNER'S - r
/1 HAZARDOUS - ROOF
-NAME (2p� ijdp r'd Gn'✓1 FIRE 'COV ERING '
AREA CLASS
ADDRESS -7 7/1 Ai i-1 EXISTING ROOF'COVERING '
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/l '/'J TO BE REMOVED TO BE RETAINED
NAME °p\`lila - TYPE OFROOF•COVERING
ADDRESS,
CITY&ZIP, , T/rrtadt/ l/�t/ r Stc�. EXISTING �T7 "... O•�' ���y "
6G_ a�r 6,c1 BUILT-UP ROOF
PHONE . ll - -
LICENSE'
ASPNALTSHINGLES cityOtcup Q,
NUMBER WOOD SHAKES
LICENSE D CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9(common-' -
cine With Section 70001 of Division 3 of the Business and Profeed s Cade, WOOD SHINGLES
and my license isi lice and effect.
License Cla r—' Lic.Number
Data . _ Contractor OTHER,(SPECIFY)
L OWNE RBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Cade: Any city or county Which requires a permit t0 c natruct, 91 to r, improve, demOlisM1,Or
reptuil env structure, prior to its issuance also requires the applicant for such BUI LT-UP ROOF -
permit to file a signed statement that he Is licensed pursuant to the previsions -
of in Contractor's License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or the,he is exempt there ;ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation o, Section
703115 by any,applicant for a permitubjects the applicant to a civil penalty
of not more mat five hundred dollars($500 ).1: . 'WOOD SHAKES
❑ 1, a owner of the property. or my employees with"wages as their sole
[Ompernalmr,Will do the work, antl the structure is not intended o offered
for sale(Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
'Law tloes not apply to an owneir of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that /
such improvements are not intended or offered for sale. u, however, the OTHER (SPECIFY). Cc:�,,
building or improvementis sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for C� -
purpose ofso1e.)'p 'PROVIDE LC.B.O. REPORT NO. 95 2!
❑ ,-aa r O1 the property, 6 exclusively contracting,with licensed
contractors to construct the proart'(Sec. 7044, Business antl Professions '
, Coda: The Contraetor'sLicense Law does not apply toanowrlproperty pROVI MFGR. INSTACLATIONSPECS.
' wh O'huilas r improves thereon, and who contracts for such projects with a -
contiactor(s)licensed pursuant to the Contractors License Law, e Gf C y 1
p em exempt ender sec.reason ,B.aP.C.far this FASTENER
If
Owns
' owner Data -
WORKERS'COMPENSATION DECLARATION '
I nareby'afflrm that 1 have a certificate of consent to saif.insure,crater -
tifi tate Of Workers'Compensation Insurance,or a certified copy thereof(Sec. /�'
TYPE J pan .
380Q Lab.CJ. II I
Policy No. CompenV Yl
1//
Certified copy is hereby furnished. LENGTH �'
Certified copy is filed with the city Inspection divisio
n
Applicant - FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not be completed 'd the permit is for one hundred dol- O Q
lora($loot qr lees.) VALUATION
I certify that in the performance or the woIrk ,or which this permit is
issued, I shall not employ any person in any manner so as to becOTe subject
m
to e Workers'Compensation Laws o,California. (M
Date Applicant - ®D
NOTICE TO APPLICANT: If, after making this Certificate of Examp don, PERMIT FEE 121. -
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must'fOrth With comply.with such provisions or this permit
hebe deemed reurkad. DATE OF APPLICATION
I certify that I have read this application and state that tike above inform.
tion i( carted agree to comply with all city and county ordinances urn ^_ O
state jams relating to building thetabove n, antl e prle, aertyfor inspection
_]( ly
pures of this city to enter upon the above mentioned property for inspection
purposes.
(We) agree to save, indemnify and xkeep
nseswharmless which
me city of Cupertino PERMIT VALIDATION
against laid City in consequence
costs and expenses which mem in any way accrue
against said City in consequence of the granting of this permit� �` 7-L)//p1 J_Signature of Applicant/Contractor _ Data V —
-REOUIRED PRE-INSPECTION 'IN-PROCESS INSPECTION - FINAL INSPECTION
'INSPECTIONS NSPECTOFW DATE NSPECTOR DATE INSPECTOfl - DATE
NO-i OSHA APPROVED-ACCESS TO ROOF SHALL,BE PROVIDED FOR INSPECTION
OFFICE COPY
Cit-q of Cupertino
10300 Torre Avenue P.O. Boa 500
Cupertino, California 95014 - Cupertino, California 95015
Telephone: 14001 252.4505
DEPARTMENT Of PLANNING AND DEVELOPMENT
SUB=: REROOFING POLICY FOR CITY OF CUPERMNO BUILDING CEPARTMOU PRIOR
TO ISSUANCE OF PE= AND INSPECPION PHASE.
1. Prior to permit issuance, you must agree to omiply with U.B.C.
standards and manufacturers spec's on reroofing.
2. New roof coverings shall not be applied without first obtaining an
inspection arra 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. r
4. In order to receive a final /
you must ool�lete steps 1, 2, and 3.
• 1. Preinspec:tion 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 CN REROOFING AND WILL COMPLY WITH THE
POLICY // /
HCHEOWNERS NAME: �0w /7uC�et5cy,
ADDRESS: $0
REROOFING CWANY NAME:
r
APPLICANT'S SIGtA'[URE
• CITY OF WPER7.'INO
BUILDING DEPARTMENT