R-4172 PERMIT R- 4172
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
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 /BUILDING USE
11 q`5 (/�b�QA�-R.n/� `QST RESIDENTIAL JZCOMMERCIAL OTHER
OWNER'S
NAME 1h� FIREHAZARDOUS / ROOF�
COVERING
AREA CLASS
ADDRESS Z� �}"LO C "� EXISTING ROOF COVERING
PHONE
��Q („p ZQ 3 NUMBER OF EXISTING COVERINGS t
CONTRACTOR'S n I,
0.` C4� TO BE REMOVED TO BE RETAINED
NAME C TYPE OF ROOF COVERING
ADDRESSgSOb
CITY&ZIa75u VvAC-fit"^C.A4 EXISTING
PHONE ��'� '12U f" -ill y BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby all the[I am licensee under provisions of Chapter 9(commen" WOOD SHINGLES
ing with Sac Uon 7000) of Division 3 of the Business and Professions Code,
and my license Is in full force and effect.
License Class- Lic.Number OTHER (SPECIFY)
Data Contractor
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED L'/' V� cs•
the Iollowinq xenon. (Sac. 7031.5, Business and Professions Code: Any city /1
or county which requires a permit to construct,alter, improve,demolisn,or
repair any structure,prior to in issuance, also requires the applicant for such BUILT-UP ROOF G~LG
P
eons it to file•signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from end the basis for the alleged exemption. Any viclnion of Section
7031.5 by any applicant for a permitubjects the applicant to a civil penalty yG
of not more that five hundred dollars(s50OH : WOOD SHAKES
oI,as owner of the property, or my employees with wages as their sale
compensation, will do the work, and the structure is not intended or offered
for tela (Sea. 7044. Business and Professions Coca: Th.Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who buotls or improves thereon,
and who does such work himself or through his own employees,provided that
such Improvements a not intended a offered for sale. U, however, the OTHER (SPECIFY) C-0-ii,
building or improv.m.nr
t i sold within one year of<omplation, the owner.
bpi Car will neve the burden of proving that he did not build or improve for
Purposeofsale.). PROVIDE I.C.B.O. REPORT NO.
0 I, as owner of the property. • ,elusively contracting with licensed
con Vac tors to construct the project (Sec. 7044, Business and Professions
ods: The Connacmr•lLicense Law do.,not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who butch, or improves thersun, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
,.son 1 em exempt under S.C. ,B.aP.c. for this APPLICATION DATE VALUATION PER FEE
owns. Dan
WORKERS'COMPENSATION DECLARATION BUlld in
I hereby affirm net 1 have a certificate of consent to sell insure,or a car
tificete of Workers'Compensation Insurance,or a certified copy thereof(Sea '1 Seismic
3800.Lab.C.). -712-51C15
r Z51C15 10'I 000
Policy No. Company I
BCertified copy is hereby furnished. Total
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION completed
ON INSURANCE Y
(Thio section need net be completed if the permit is for one hundred ddb I�
bn IS100f or less.) `II
1 certify that in me performance of ma work for aswhich
this permit it
issued, shall not Compensation
any pawn In any manner to as to become subject
fes the Workeri Compmsetion Lam of Californian
Date AT: If.
NOTICE ld APPLICANT: o he W making this CertCompensation
p of Eons ofithe
you should become subject to the Workers' Compensation provisions a me
Labor ccee,you must forthwith comply with such p•oyitions or this permit All roofs shall be inspected prlorto anyxoofing material being
shall be deemed evoked.
I certify that I have rend this application and safe met the above iftforma Ins d. If a roof Is Instal Rd Without first obtaining an
fifth is correct. 1 agree to comply with all city and county ordinances and Ins act ,I agr a to remove .illy esu materials for s ectign
Nb blaws relating to building construction, and hereby authorize represem fS/
relives of this city to enter upon the above mentioned property for Inspection
purpose.. G
v agree to save, indemnify and keep p harmlessthe City of Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in consequence of me granting of this Permit. IGNATURE F APPLICANT DAT
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
SUBIECI': REROOFING POLICY FOR THE CI"IY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERIvUT AND INSPECTION PHASE.
1. Prior to permit issuance, you "lust agree to comply with U.H.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings strait not be applied rvilttou( first obtaining all iuspection and written approval
from the building inspector. A final i"specdo" and approval shall be obtained train the building
i"speclor when Ute 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 "lust complete steps 1, 2, and 3.
1,) Preinspeclion or (car off approval.
2.) In progress inspcclio"approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor iustallalion
5. If plywood is installed, a plywood nail inspection is required.
G. If any roof is applied without first obtaining au inspection, you will be required to remove all "ecv
material down to the shcathi"g and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON RLROOFING AND WILL CON PLY WITH THE
POLICY
HOMEOWNERS NAME: �Lc` rVAVM\
ADDRESS:
REROOFING COMPANY NANIE:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroor/winword
i
is
I
•
Call of CNperti"O
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply with Section 1210-a of the Uniform Building Code.
Section 1210-a requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted oil the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to roost used for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have sm Ike detectors
installed that do comply.
GZS V
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE:
DA'Z'E:
I
winword/smkdet
•tiy�c