R-4177 PERMIT
APPLICATION FOR CIN OF CUPERTINO NUMBER R- 4177
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PER EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 130 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
J� BUILDING ADDRESS BUILDING USE
gplAi? RESIDENTIAL COMMERCIAL OTHER
OWNER'S
C'i. /Jl -• 1 HAZARDOUS ROOF
NAME C( /�.�.MA-J FIRE COVERING
AREA CLASS
ADDRESS �- EXISTING ROOF COVERING
PHONE ✓ �. 047-191 NUMBER OF EXISTING COVERINGS Z
CONTRAC S
�� TO BE REMOVED •� TO BE RETAINED
NAME�nc�t, /CA�I TYPE OF ROOF COVERING
CDD&(ZIIP /Z !J of y V EXISTING
PHONE](LL�Q� C. 7 BUILT-UP ROOF
LICENSE /� / / / / ASPHALT SHINGLES ?'
NUMBER li O 16 10 b
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
with
.tion the[I of licensee 3.1 t e B..ions Of Cn spur 9(commen.
cine with an Hon ]000) of Division 0 of Na Bu.inan and PnoLuiom a., WOOD SHINGLES s
mtl my C IF �I���vl1n�ilj�P ce and effe<t. /
DataLicel,yTAIVCE Lic.Numba OTHER (SPECIFY) � l
Data AAl�IX_f Comrector
GI
OWNER-BUILOER
mpts DE the RATIO 7
herabyQ Hirth that I am exempt from the Contractor'sessiLicense Lew for PROPOSED J9
the lollowin navrn. (Sec. 7031.5,in Business and Professions Impr Coda: Any city
unto wnict r.,Prior• permit to construct..also re alter, he applicant
tlemoli uch
P.=env Is a sin,prior to In ithat h i ciao sed Pur that to them for such BUILT-UP ROOF ry Gr Lf//-:,•
P.= to ills a signed statement ane[he is licensed pursuant to the provisions w
of Ma Contractor's of the
Llcama Lew IOhapter 9feali. . (commencing at a IM1 ..,or the,. y0� 4 ere
I Dmind the th.efor the and alleged
ex m conal p1 that is of Section BrASPHALT SHINGLES .J—I
bom and [ne applicant
for for ellermi exemption. Any violation Of pnat
of not by any 1 five ant fora permit subjects the applicant t0 a Civil penalty
of not mora trio.fin hundred pro erty, I my em WOOD SHAKES
❑ 1, ti owner of [M1h property, or he employan aim waves of thou free
Com al*(Sec.
will do tris work, and the fCode is net intended License WOOD SHINGLES
for do(Sac. ]094, to Business andProfessionsfratCode: The orimprveContractor's hereon.Law aper not apply toe o1 through
who build,to impr Pref demon,
and who tlova w<M1 work himself, int or ed or h M1ls own employees, however,
tern
such n, or improv a his old wits P.one
year
for cele. If, nothe o me OTHER (SPECIFY)
buuai, o. improvement t e bur is apltl within hat year of completion, inn owner
Purpose
will new the burden of proving that he cin not build or improve for
propose of sown PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner st the property, em exclusively Business contractingwith licensed
code: The .o tractor's the project (Sec. t app Business nna entl Pronasions
who Tera Contractor's.heron Law doeswho notapplyfor
owner such
project.
with PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves.nester, and who contracts mr auto prolec<s with e
contractor(s)amm Pte pursuant to the ContreE[or•s License Law.
❑ em ...mpt unser Sac. 1 ,3.&p.C.for to if
.sacro APPLICATION DATE VALUATION PERM EE
Ow Dau
nen IK WORKERS'COMPENSATION DECLARATION Building
I M1anby affirm .net 1 neva•certificate of consent to selfcopy
.her o / /��� '
[ilkm of Workers'Cot I have.c Imur or sertH lea Copy thereof(Sec. S `/sy/' $813mIC
3800,Leben � �
POI N.
�Certifin1 copy n hereby furnished. v Total
Certified copy I the Pedro 'urn
Applicant A,+� E in ♦ 1
CERTIFICATE,6F EXEMPTION FROM W KERS' N.C.
O ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section head not be completed if the Permit is for one hundred Bol-
len 161001 pr lao.l
I certify sh that in ma performance of the work for anion eo permit is
louse, I snail not employ any Lenon in any manner so of to become subject
to me Workers'Compensation Laws of California.n
Den Applicant
NOTICE should
APPLICANT subject
. o celer making this Car tion a of Eons of
you .M1oula become epblect m ms Workers' Compensation provisions o1 me
Labor Code, you must forthwith comply with such Provision.or this permit All roofs shall be inspected prior to any roofing materialbeing
.hell be deemed invoked.
1 certify that I nava read this application and stets 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 end inspection,I agree to remove all new materials fon spectlon
.,at. laws swing to building construction. end hereby authorize reprosen
naives of this city to anter upon the above mentioned property for inspection
Purpose..
(Wel agree s. sew, indemnify costs
and keep esharmlesswhich the City of Cupertino 4(
against said
i id liabilities.I consents,Coln ane expenses f this
they in my wry aCCrvO
I .vmft fail clay In conropr.nce of me granting of mil permit. SIGNATURE 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 r
OFFICE COPY I
SUB1ECf: REROOFING POLICY FOR TILE CI'IY OF CUPERTINO BUILDING DEPARThIENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you umst agree to comply Willi U.B.C. standards and manufacturers spec's
Oil 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 wherr 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 must complete steps 1, 2, and 3.
11) Preinspectioit or fear off approval.
2.) In progress inspection approval.
• 3.) Filial inspection approval.
a.) Operable smoke defector verification
b.) Spark arrestor installation
5. if plywood is installed, n plywood nail inspection is required.
6. Ifany 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 lime.
WE UNDERSTAND 111E ADOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOtv1L-OWNERSNAIAE:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE: 9
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword