R-4433 APPLICATION FOR PERMIT
CITY OF CUPERTINO NUMBER R� 4 4 3 3
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM IT DAYS OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING O\R' \ J \ESS ^ -^^ BUILDING USE
�'^'��1• RESIDENTIAL COMMERCIAL OTHER
-
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS �Qy�S _1.L��1k ��IjOI EXISTING ROOF COVERING
n
PHONE —a, NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO SE REMOVED TO BE RETAINED
NAME N )0-1C% TYPE OF ROOF COVERING
CDY&is
IITbfd�`.Q�\�1 �"(�S� t EXISTING
PHONE �V U J v "1'�--`-' BUILT-UP ROOF
LICENSE �� (� ASPHALT SHINGLES
NUMBER _ ` P A O
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I herwith
affirm 70001 of liunea 3 of pro.,iona of d Fpter 9or..(Coons C.-o- p�qq ''''�pp`�
mIng with an"Section 7o 11 of Division 3 of he Bwinoa and Pr WOOD SHINGLES NAR a Wig
tl mY Ilunse p In yu a effect.
Liceme Ca - LC.Number
Dew —
contractor z OTHER (SPECIFY)Ci-fY
OWNER BUILDER DECLARATION UVYCFII(NO
I hereby affirm that I am exempt from the Contract.,'. License Lew for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city �7
or county which requires a permit to construct, sitar, Improve, demolish,or \7
repair any structure,prior to its issuance, also requires the applicant for such BUILT-UP LT-UP ROOF
air
Permit 10 file a signed statement that he is licensed pursuant to the provision d
of the C
ontrecloi s License Law (Chapter 9 (commencing with Senior)000)
of Division 3 of the Business and Professions Codel or that he h exempt them ASPHALT SHINGLES O�
from and the anis for the alleged rmi exemption. Any ant to
or Section
7031.8 by any t ve hundred
u fora permit subjects the applicant to e civil penalty
of nor mor.that fir.nu.pro eons r my e 1 WOOD SHAKES
❑ 1,a ar of the property, or he employees with wends as r sir sola
'or safe (Sec.
044 ass the work, and ms nrpmgro is not intended or License WOOD SHINGLES
for fila (Sec. apply
Business dna Professions Ohaa: The or Contractor's License
Lew does not apply to an owner of property who builds to ees, oras[hereon,
dna who eon such work himselfint or through fir own employees,provided that
such ngproverrentsimprov are not old wife or offered for fib, If, however, me OTHER (SPECIFY)
building or improvement i sea within one year of of build
the owner
builder will neve me burden of proving mu he die not build or improve for
Purpose
1 orsown PROVIDE I.C.B.O. REPORT NO.
❑ I, a st me Property.je t ( ec.704 , contracting n win licensed
contractors m construct me project (Sec. 7oeA, Business and Professions
Code: The Contractor's License Law does not apply to an ow of property PROVIDE MFGR. INSTALLATION SPECS.
Who ouilas or improver hereun, ann
d who conects for such projects with e
contractor(.)licensee pursuant to the Contractor's License Law.
❑ 1 am exempt rhea. sac. ,esP.c.for this APPLICATION DATE VALUATION PERMIT FEE
,..son Da[. / ✓1
Own., WORKERS'COMPENSATION DECLARATION �J f J y (7 p(Vi�'�� Building
I hereby affirm that I have a certificate of cogent to self.insure,o \0Ln "I 1 `�I IA/N0 o
tificen of Workers' Compensation Insurance,or [ilia opq the not ISec. 3BIsmIC
3600,Lab. LI'1/�� V
Policy No. �1�^y/��L�2 Company Total
BCertin� opk -y is hereby furnished. - I
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N O ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred doh
len(d, I or lass.)
1 certify that in the performance of the work for which this permit is
issued,
I troll not employ any persono in any manner so as,o become sublet,
to the Workari Compensation Lews of California.
Data NT:AppIf,[
NOTICE should
APPLICANT: o hear, making this m.stioute . Exemp[i tin,
you rCod become see bort, i the Worked' Compensation provisions a the
shall Code, you roger rermwim comply with .,,ter prori.iLns or this Permit All roofs shall be inspected prlorto any roofing material being
shall be deemed revokatl.
l certify met I have sad his application and rote min
he,the above forma Installed If a roof Is Installed without first obtaining an
bon is correct. I agree to Comply with all city mod county ordinances and Inspectio agree to remove all new materials for Inspection.
auto laws relating to building construction. dna hereby authorize reprnem
[.dives of this city to enter upon the above mentioned property for inspection p
purposes. 'LFW^.
(W 1 agree to save, indemnify and keep harmless the City of Cupertino 1
.gained labilitias.Judgments,costs and expenses which may in any way accrue
awinat said City in conseque....I he granting or this permit. SIG 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 UII
OF CUPERTINO BDIVG DE?PRT lENT
PRIOR TO ISSUANCE OF PER.NaT AND INSPECTION PRASE.
1. Prior to permit issuance, yeu must agree to comply with U.B.C. standards and manufacturers srec'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 the building
inspector when the reroofing is comole:ed.
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,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor insWiation
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.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL CO11PLY WITH THE
POLICY
HOMEOWNERS NAME:
-\ G
ADDRESS:`
REROOFING iG COMPANY NA2vM:
APPLICAtiTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
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