R-4203 PERMIT
APPLICATION FOR oh. CIT` OF CUPERTINO NUMBER R- 4203
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IN DAYS OF PERMIT NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS II �i BUILDING USE
10323 0)I fC L /,^`�`Vf` RESIDENTIAL COMMERCIAL OTHER
OWNER'S
C1er, �Oj HAZARDOUS ROOF
NAME Clem ���JJJ \/r ' FIRE COVERING
+ I f AREA 1 CLASS
Ave EXISTING ROOF COVERING
ADDRESS—
PHONE
DDRESS I,
PHONEAJQq1 �& _1 NUMBER OF EXISTING COVERINGS
CONTRA 'S
NAME �, �F� /-1 ` .I� TO BE REMOVE TYPE OF ROOF COVERING ED
CITY&iso LP —r • ���CG �� EXISTING
Ire1QVr) ') –� BUILT-UP ROOF
PHONE
LICENSEASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
1 hereby affirm that am licensed under a au.lrn. of d Have 9(Common
cine with section 70001 of Division 3 of the ausinety�n�Pro�n�iym code, WOOD SHINGLES
and my licaqme rarca and aibm. N(uC/ I /
Data 1 Contract., LJ OTHER (SPECIFY)
Dela
WNER-BUILDER DECLARATION
1 hoeb, :firm met 1 am...Trial fr.,the Contractor's License Lew for PROPOSED
the fonowinp reason. (Sec. 7031.5, Business and Professions Code: Any city
or coonIV Which requires a permit to construct,alter. Improve, demolish,or
repair any ,, clue, prior to its issuance„also requires the applicant for such BUILT
ROOF
.armi0 to ills a signed statement that he Is licensed pursuant to the provisions
01 the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
of It
3 of the Busmen.and Professions Code)or mat he is exempt her. ASPHALT SHINGLES
from entl the basis for the alleged exemption. Any violation of section
from a d any basis
for for a Permit xempti the applicant to e civil penalty
of not more that Ove hundred dollen Is900).): WOOD SHAKES
❑ I.as owner of the property. or my employees with wages ea[hair sole
compensation, Will do the work,and the structure is not Intended or offered WOOD SHINGLES
w
for cele (Sec. 7044, Business and Professions Code: The Connector's License
LaBoas not apply to an owner of property his
builds or improves thereon,
and whodoe does such work ovine or through tris own employees,provided Met
such improvements are not intended or offered for tale. If, however, the OTHER (SPECIFY) ncvm
bur ming or improvement is sold within one year of completion, The owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner
of me property, . exclusively contracting with licensed
contractors to construct the project ( ec. 7044, Business and Professions
Code: The Contractors License Law does not apply to on owner of properly PROVIDE MFGR. INSTALLATION SPECS.
Win o builds or improves thareun, and who contracts for such projects with a
coetraCsorb)licensed Punu..1 to Me Contractor's License Law.
❑ 1 am exempt under Sec..,B,&?.C,for this
APPLICATION DATE VALUATION PERMIT FEE
Owner Data e- Dp�
WORKERS'COMPENSATION DECLARATION 1V Building
I hereby affirm Chet have a certificate of consent to self-insure,or a Car Ie
lift 'a
at Workers'Comae nset ion Imm�nca,or a certified copy thereof(Sac. �� O Sel3mIC
3800, Lab.Cd. V 199,5
Policy Certified
Company
- 2`
Bcertn.a toper is hereby wrm.p.d. (tilts 1/� L Total
Certified copy is filed with the city inspection division. VI' (
Applicant VUN -U
CERTIFICATE OF EXEMPTION FROM WORKERS' N `, P HMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one huntlred do
bra 15100)o.htel. ( /7*
certify at in Ma per}Ormenca of the work for whichn Mit permit is
issued I shall not employ any person in any manner so as to become subj.ct
to the Workers'Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: It, atter making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions or the
Loop'Code,you mutt forthwith comply with such provisions or this permit All roofsshall be inspected prlortoany roofing materialbeing
shall ba deemed revoked.
I certify that I neve read this application and slate that the above informa installed If a roof is Installed without first Obtaining an
tion it correct. I agree to comply with an city and county ordinance.and Inspection,l agree to remove all new, to als for inspection.
.1.1. laws relating to building construction, and hereby author.,. rear...,
btives of this city to enter upon the above mentioned property for inspection
(Wt liabilities.agree uv in ts,cos s antl bap es which Ina City of Cupertino
against sidtyi Consequence
costs and expenses which may in my way------
against
trw
Ayines said City in con..openc.of ma granting or this peruse. 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
OFFICE COPY _
SUBIECI': REROOFING POLICY FOR 'fi1L CITY OF CUPERTINO BUILDING DL•PART,MENT " r�
,
PRIOR TO ISSUANCE OF PERr UT AND INSPECTION PRASE. : -,•
1A�in�n.
1. Prior to permit issuance, you must agree to coruply with U.B.C. standards and manufacturers specs
on reroofing.
' 2. New roof coverings shall not be applied without first obtaining all inspection and written approval .
from the building inspector. A final inspecliou and approval shall be obtained from lire building
inspector wherl lire reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
,a
d. In order to receive a final,you must complete steps I,2,and 3. «, y ,
1 J Prehispectioir or tear off approval. ._ ,• ra'e
2.) In progress inspection approval. „J<.
3.) Final inspection approval.
• .. - r''. - . v •
a.) Operable smoke detector verification ;; •,.+14 j £ r
{hY, 4
b.) Spark arrestor inslallatimr
5. if plywood is installed, a plywood nail iirspcctiou is required.
G. If any roof is applied without first obtaining an inspection, you will be required to rcnrove
material down to lite sheathing and a building inspector will inspect all sheathing at Wal Hula
WE UNDERS'T'AND 11113 MOVE POLICY ON IZE•1100FING ,AND WILL COMPLY WITII TIIE
POLICY r
I101AC.OWNERS NAME:
ADDRESS: -{�� Ave
RERoor•]rlc COMPANY NnmIE:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT "%
Rcroorlwimvord
4
i
AdkA
i
Citsi of curT¢J'ti"O
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply with Section 1210-a of[lie Uniform Building Code. ;:• s;,,
Section I210-a requires when repairs to a single family dwelling exceed 51,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping room and ata ;, C
• point centrally located it, the corridor or area giving access to room 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 smoke .detectors,,
installed that do comply. "
ADDRESS: t l0 3 ne ( Aix ,.
4e
PERMIT NUMBER: 120 ; 'P
HON OWNERS SIGNATURE:
DATE: /� 0 /• l�J :,
- � JAZ•;
3•J
winword/suikdet 1 w::.•