R-4069 PERMIT Res 4069
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(498) 252-4505 EXT. 228 RK IS NOT STARTED
WITHIN 180 DAYS OF RMIT EXPIRES IF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
I//nE "L,r RESIDENTIAL COMMERCIAL OTHER
OWNER'S 'I"l�fi�.Q.� LIJ E-Y
HAZARDOUS ROOF
NAME FIRE COVERING
AREA ��`"'ll.V// CLASS
ADDRESS EXISTING ROOF COVERING
PHONE 1J �S -S�S p NUMBER OF EXISTING COVERINGS
CONTRACTOR
V
ONTRA TOR'
TO BE REMOVED TO BE RETAINED
NAME -/-pmt �y TYPE OF ROOF COVERING
ADDRESS / /� p T/� f
CITY&ZI{' ^Z� /l -,D`a dv�Li1 EXISTING
PHONE .�s> 56� 7� 49 BUILT-UP ROOF
NLICENSE UMBER Zlo 10 fl ASPHALT SHINGLES
WOOD SHAKES ,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensedneer provisions of Chapter 9(common
-
ing with Section 7000) of Division 3 of the Business and Profenlons Code, WOOD SHINGLES
and my
Lice [.
o.tNumb
DetCptCnractore
OTHER (SPECIFY)
0 NER-BUILDER DECLARATION
I hereby affirm that I am..amps from me ComraCt.e. License Law for PROPOSED �.
I following reason. (Sec. 703 Sp eunnan and Profmion$Code. Any city
re4county which requires a parmit to Construct,eller,Improve, damolifn,or 19q
ir any structure,prior to if.muince,also requires the applicant for mch BUILT-UP ROOF0'
permit to file a signed moment mat he is licensed pursuant to the provisions (
of he Contractors License Law (Chapter 9 (commencing with Section 7000) `` -- \�w
of Division a of me Business and Prof...ion.C.d.l or that he I.exempt her. ASPHALT SHIIOLES
from and the bell. for ms all.psd exemption. Any violation of Section
7031.6 by any pp ant fore parmit subjects the applicant to a civil penalty l!
f3.1 mor.th.f tiv.nunmed door.( 600).1: WOOD SHAKES.`y kY
❑ 1,as owner of the property,o my employees with wages n their sob G�
compensation,will do the work, andhestructure is not intended or offered yy00D SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Conloctoi s License
LOW dost not apply (O an owner of property who builds or improves to.rear,
and who do"such work nimHlt or through his Own employees,provided that
such improvements ere not intended oroffered for sale. If, however, he OTHER (SPECIFY) G�
building or improvement is sold within on. year of Completion, the Owner
builder will have the burden of proving that he did not build or Improve for //f�JKYN
Purpose Of 1.4..). PROVIDE I.C.B.O. REPORT 0.
❑ 1, sa owner of the property, a ¢Iuaively contracting with licensed
Contractor: to construct the project (Sec. 7044, Business and Professions
oda: Th Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves [heron, and who Contracts for such projects witn e
contractor(s)licensed pursuant to the Contractor's License Law.
reason 1 am exempt under S.C. ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT F E
Owher Date
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that 1 have a certificate of consent to• H insure,or a car
[ificate of Wor arypanosation ad cypy areof Isar. �/5� /2 L)1_117 lam" Seismic
Poll Laoe. ILIL.nrew J7
Policv�+ C Company
�.cotsaed copy is hereby furnished. Total
YD Gnitiadc�y is w'Int t'impgyn4 - ®-
Applicant cc
ill( LYES
CERTI FIC E.FIC E OF EM XEMPTION FRO WORKERWoRKER O PERMIT AUTHORI TION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
tars($100)or less.)
1 certify that in the performance of the work for which this permit is
V
issued, I .hell not employ any person in any man er so as to become subject
to in.Work.a'Compensation Laws Of California.
Data Applicant
NOTICE TO APPLICANT: If, attar, making this Certificate of Exemption,
You should become subject to the Workers'Compensation provisions of the
Labor Cod., you must forthwith Comply with such provisions of this permit All roofs shall be Inspected prior to any roofing material being
shall be deemed rooked.
I certify that I neve read this application and state that the above inform. installed If a roof is installed without first obtaining an
tion is correct. I agree to comply with all City and County ordinances and Inspection,I agree to remove all new materials for inspection.
atate laws rebting to building construction, and hereby suthor11. rripresao
tativo of this city to enter upon the above mentioned property for inspectionpur
IW 1 apnea to awe, indemnify and bap harmless the City of Cupertino • ✓ G
against liabilities,ludpments,costs and expense.which ------
alienist sold City In consequence of the granting of this peermit.any way.ccru SIGNATURESIGNATUREQF APPLICANT q 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 171E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply will' U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall 1101 be applied wiU'out first obtaining all iuspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
iuspector whet, 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 "lust complete steps 1, 2, and 3.
I,) Preinspection or tear off approval.
2.) In progress inspection approval
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installati0u
5. if plywood is installed,a plywood jail inspection is required.
G. If any roof is applied without first obtainijg all iuspection, you will be required to remove all new
material down to lite shealhiug and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME:
ADDRESS: 1OZ03 aiJ. ��•c�e—ems
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
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