R-4009 APPLICATION FOR PERMIT R_ 4009
CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS J(� `� / `�/"gyp / BUILDING USE
IL-1 V — I^I I " n� r v RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZAROOF
RDOUS ECOVERING AREA CLASS Cj
ADDREXISTING ROOF COVERING
ESS-
PHONE ' I NUMBER OF EXIST N�OVERINGS
CONTR OR'S
ti TOB E
OBE REMOVED TO BE RETAINED
NAME TYPE OF ROOrCOVM1NG
ADDRESS
CITY a ZIP //�C Q EXISTING
�L J
PHONE BUILT-UP ROOF
LICENSE ASPHALT SHI UFS
NUMBER
WOODS KES
LICENSED CONTRACTORS DECLARATION e
I tenby affirm that I am lic•mad under provisions of Cbapto B Icommem
any with Saccon 70c0�of Oivi.ldn 3 Of the Bull as . Pro'...Iona Cada, WOODS INGLES
and mylicense' Jn II pand.".c[.
D.. 19 Conic.tract OTHER (SP IFY)
1 R-BUILDER DECLA 10
I nosy dlir met em exempt from the Conoacto:. Licam. Lew or PROPOSED LP PI
the following reason. (Sac. 7031.6, Business and Professions Code: Any city lel/
county which requires a permit to construct, alto, improv., demolish,or
repass any structure,prior [d lea issuance,also requires the applicant for such BUILT-UP ROOF
P.= t0 111.s signed tat.m.nl tnrt he is licensed off rauem to me provisions
of ma Cone3 otri License s Lew (ChapterProt
s Cod.)
(commencing with Section 701101
here
from
Division 3 of M.Bfor In and alleged
exemption.
Codes or that he is n mut coon ASPHALT SHINGLES
Irom antl the basis for ma allayed exemption. Any violation OI Section
7031.6 by any t five ant for s poll...
f500)Je In..DDlitent to•civil penalty
of not more
twee Doe the pro dollen my em WOOD SHAKES
❑ I, a In of [rte property, or he employee+with wayae de r air sola
compensation will do ma work, and the structure N not intended or defend yy00D SHS GSL d .�
for sale(Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds or improves thereon. ,
end Who does such work himself or through his own employees,provided that Jy
each improvements are not intended or offered for sale. ff, hoW.v.r, the OTHER (SPECI�PN�.� 199„s
building or improvement is sold within one year of completion, [he owner Nr
builder will have to burden of Droving ins[ he did not build or improve for �1y�
purpose Ofsal..l. PROVIDE I.C.B.O. REP0h/FCNO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to connruct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build, or improves thanun,and who contracts for such projects with a
contractor(s)licensed pursuant t0 the Contractor's License Law.
❑ 1 am exempt under Sac. ,B.&P.C.for this
ow D.ta
APPLICATION DATE VALUATION PERMIT FE
war WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that 1 have a certificate of c sant to Bell insurs,or s r / "6d
3800 pp k o enter{' co thereof l a /�-�� $el$mIC
PolicllgC r�ri lnpen op- y t /�/ y
``�Cjj JA ,rt11116` (`J'% I .`JAciYvl
Policyy C.rtib.e c v her y fol'lle, 1. Total
"DSC yfie .0h .pacbm db,pon.
Applicant
CE IFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Twis section need not be completed if the permit is for one hundred ddb lam/ I `�y 1
lar.(flcc)or las.) 1/
1 certify Inst in the performance person
01 n, work for anion mit permit is �\
issued'.teI +hell not employ any we o in any m.n ar,o e.to become W bject
to the Woskoi Compensation Lew+of Celitornia.n
Data Applicant
NOTICE should
APPLICANT: if'. alto making phi. Certificate of Exemption,
you should b•coma subject i the Work tri h such pro ion provision of he
she$I Code, you muse forthwith comply with ten proyisinns or this permit All roofsshall be inspected prior to any roofing material being
.hall De d.Omatl I.yOked.
I certify that I haY.read oris application and state that the above Informs installed If a roof is Installed without first obtaining an
tion is corrace. 1 agrao to comply with at city and county ordinances and ingpeCtlOfh l sore to remove all new maters I forinspection
rtaa I•w+ rate tinp to building construction, and hereby aumoriee r.prasem 9
pulpas of mis city to anter upon the above mentioned property for Impaction ' /a
purPmas. 1//AI /VI�l11l NIy4(/ a/rr�.r
IWt liabilities.apse. sew, indemnify antl keep M1Omlseh m. City of Cupertino
•yainst id ityi consents,costs of andthe expenses which is may In anV weY aCCru•
awn+*+•ia City in mn+aquanpa of m•granting of this permit. SIGNATURE OF APPLICANT ATE
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
SUBIEC7': REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issualice, you ,just agree to comply with U.H.C. standards and manufacturers spec's
on rerocGng.
2. New roof coverings shall ,ot be applied without first obtaining all iuspectiou and written approval
From Ilre building inspec(or. A final iuspectiou 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.
d. In order to receive a final,you most complete steps 1,2, and 3.
1,) Preiuspeclion or tear off approval.
2.) 1, progress inspcclion approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verifrcalio,
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail iuspectiou is required.
G. Ir any roof is applied without first obtaining au iuspectior, you will be required to remove all new
material down to the sheathing and a building i,spector will inspect all sheathing at(lint time.
WE UNDERSTAND 771E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
IIOMEOWNERS NAME: n
ADDRESS:
REROOFING COMPANY NAME:
till I/APPLICANTS SIGNATURE: 0� ��
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword