R-4020 PERMIT R- 4020
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
iW DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS \ BUILDING USE
5 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME Nog'-w. .1�a�+ Q, A HAZARDOUS ROOF
FIRE IVB COVERING A
►� I _`` �� 'I AREA CLASS
ADDRESS-�yj O g $l� NO(-Apolti `^T EXISTING ROOF COVERING
PHONE 'r IS /.� 2 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �1
To.��,r T�6�T:110. Ca , TO BE REMOVE TYPE OF ROOF COVERING ADDRESS
ED
NAMEp
CITY&Zia 0 5 / 4,re4z�ii' EXISTING
PHONE 771 - 7500 BUILT-UP ROOF
LICENSE "16 :2.0 IO ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 bnbV affirm that 1 em licensed under
Lntler prrvisiod of Chapter 9(comment
Ing with Section 70D0) of Divi.ion 3 of me Business and Plot...Iona cod., WOOD SHINGLES
and my license If iprU ..and effect.
Licari Clea �/' Tic.Number
Dae. con[rac[rr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt ,rpm the Contractor's License Lew for PROPOSED
the,ollowing reason. (Sec. 7031.5, Business and Profession.Code: Any city
of county which .quire, a permit to construct, altar, Improve, demolifb,or
,.Pair env.,tru.t.r.,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit to 1I I.a signed statement that he if licensed pursuant to the provisions
Of the
Contractor'+ License Lew (Chapter s (commencing with exempt 7000)
from
Division 3 of the Bfor the
ma PmMuom conal or mss he a exempt ,i. ASPHALT SHINGLES
M1rm assn the buff for for apermi exemption.the
Any violation or Section
7031.5 by any applicant In ,ore dollars
subjects [ha ePPli[ent t0 O Civil P.ne1tY
or not more that nye funm.d er y. 1%y em WOOD SHAKES
I,ti owner of me Property, pr he employees with wend as their sale
compensation 81&(S ,will ass the work, and the structure if not intended or License WOOD SHINGLES
for sale(Sec. )099, to neo and Professions operty whnst The ds Convertor's License
Law non not erre, to an owner of through
is o buildslo Improves provided
that ////ffff
and who
rod such work
re nim.,or eM1 fou ph fir own employee., however.
that ct 5k �<e
such imp.ovemann are not intended or offered fo. .l., n, noweva.. tree OTHER (SPECIFY) .�/t
building Or improvement sold within one Year o,completion, the owner
builder will have the burden o, proving that he did not build or improve ,or
purpose
of PROVIDE I.C.B.O. REPORT NO.
D I, of owner st the property, t ( ea<Iu 044, Business contractingwith licensed
cone Thetor. to construct Cha project (Sec. tsps town owner ane Pr property
Corr Tbs ornvacros Licsnsi, no doesWho cotaPpts Poen hproje property PROVIDE IP INSTALLATION SPECS.
who actors or improves t end ons contract,for such projects with a
contractors)licensed oderSpursuant to the Contractor's License Lew.
p I .m ..amps um.. stet. ,B.a P.c.,or his
cadre APPLICATION DATE VALUATION PERMIT FEE
Ow Dna ei
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that I neve a certificate of consent to selbinsure,or a carsal
3800te of won Compensation Insurance,oronscertifiedscrpv t e aof(S.c. P p I D �� — —^ $915mIC
3800,Lob. •� 1 - M ( ( V 1
Policy No. `( Company :5+19L 1 �W
8 Certifier copy is hereby furnisher. Total
cern,Pad�.dpy tty� ate trity inspection division. 111
Applicant ,P1
CERT ICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ P AUTHORIZATION DATE
COMPENSATION INSURANCE SIL
(Tref,section need not be completed it me permit i,for one hundred dOI. ' Ur CUPtHI INU
1 toasty that in the performance of the work ,or which this permit if
issued, 1 shall not employ any Lenon in any manner so as to become subject
to the Workari Comp.n,ation Low.of California.
Dan. Applicant
NOTICE ler APPLICANT: o altar making this Compensation
sof Exemption,
youLab should D.COme subject i the Work elf h such provisions
provisions this Of the
Labor code, You must forthwith comply with .pore Droyi.ion+or this permit
thele be deemed rooked. All roofs shall be inspected prlortoany roofing material being
I certify that I have read this application and state that the above inform.. Installed. If a roof is Installed without first Obtaining an
tion i. coast. 1 agree to comply with an city and county ordinenc.f and insp I agreeto removeall new materials for inspection.
nate bw, relating to building construction, end hereby auth.1ic. Papresam
Pulp. of this city m anter upon the ebove mentioned Property,or insp.ctirn i- v 'J �l�r 19
Dur Poses. pi'."'s.�T/
IW.1 apnea to uv., indemnity and keep harmless the City of Cupertino
against liabilities,judgments,costs and expenses which May In any war accrete
."Inst said City in consequence of the granting of this Darmit SI ATURE OF APPLICANT DAT
PRE-INSPECTION: PLYWOOD: I N•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 TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERfv11T AND INSPECTION PHASE.
1. Prior to pencil issuance, you must agree to comply with U.H.C. standards and manufacturers spec'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 iuspeclion 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, lit order to receive a final,you uurst complete steps 1, 2, and 3.
1,) Preiuspectiou or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
aJ Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywood uail inspection is required.
G. If any roof is applied without first obtaining mt iuspeclion, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY *`
HOMEOWNERS NAME:
ADDRESS: c8bo
REROOFING COMPANY NAME: cc)
APPLICANTS SIGNATURE:
• C17Y OF CUPERTINO
BUILDING DEPARTNIENT
Reroof/winword