R-4595 APPLICATION FOR CITY OF CUPERTINo
NUMBER PERMIT
R— 4595
.,INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ' J
In- - L4 f J' '�✓ RESIDENTIAL—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
I-� YES ❑ If yes-1 understand that a Class A
NAMEcf���) I NO roof assembly is required.
nitial I.C.B.O.tt
ADDRESS LA A IV D'Y 'W EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS _ 1Z
CONTRACTO S
�n 2_� C+X� TO BE REMOVEDTO BE RETAINED
NAME t1
ADDRESS / _ ,�aaa� 1 -tom �,pJ,'Kn TYPE OF ROOF COVERING
CITY&ZIP— I `o� C_Q- I �r � 1 r �+' / 1
(; k1M�3E(�l_ 9Sco$ EXISTING
PHONE— BUILT-UP ROOF ❑
LICENSE
NUMBER <^I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES-
7000)o1 Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
09"'? 3'u> WOOD SHINGLES El
Licanae Clea ` Lic.Number
Data�.�..o.�-�contractor QC--g/sak f Lr( OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from
the Contractor's License Law for the bitewing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a 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 therefrom and the basis for the alleged ASPHALT SHINGLES01
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work'and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Cade:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such,mprovements are not intended or offered for sale.If,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulld or improve for purpose of sale.).
❑I,as owner f the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractorts)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El I am exempt under Sec. ,B&P.C.for this reason
Owner oat. APPLICATION DATE VALUATION PER T FEE
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declaration:
Z antl will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
asp vided for by Section 3700 of the Labor Code,for the performance of the work for which this ��-, �y"kr
permit is Issued. may/ /i�"J SgISrnIC
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Pp Al �t
_the Labor Code,for the performance of the work for which this permit is Issued.My Workers P A D
Compensation insurance carrier
and Policy
number are:
Total
Cerner �`� �`^'x'`x'^ Policy No. _ 13-7
� MIT AUTHO ON DATE
CE FICATE OF EXEMPTION FROM WORKERS' Offs KIP
COMPENSATION INSURANCE N.CQ
(This section need not be completed it the permit Is for one hundred dollars($100)or lk-)y Ulf. <,UrFH
I certify that In the performance of the work for which this permit Is issued, shell net employ
any person In any manner so as to become subject the Workers'Compensation Laws of Celi All roofs.shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data �o Applicant inspection,I agree to remove all new materials for inspection.
NOTIc APP CANT: If,after making this Certlflcate of Exemption,you should become Applicant understands and will comply with all non Dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above information Is correct 1 agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof verings to be cl Ss"C"or bbetttttterDC/�'J///h/Jy//Jo
hereby)agree
representatives of this city to armee upon they of Cupertino
a property for im /�-J
spection purposes.
(We)agree to save,penseslw and keep hay way the City ai Cupertino against liabilities, 7
ofthe gran costs and expenses which may in any way accrue against said City In consequence � U' E OF APPLICANT ATE
of the granting of this permit.
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
v
Citv of
Cupertino
SMO F-D TECTOR 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 on the ceiling or wallin each sleeping room and at a
point centrally located in 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:
PERMIT NUMBER: 4 5-95—
HOMEOWNERS SIGNATURE: ✓'� t�' \
.DATE: 2- 9 6L 19 95
winword/smWet
Printed on Recycled Paper
if
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!• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on 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 when 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.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
• 5. If plywood is installed,a plywood nail inspection is required.
6. If any 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 time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
. POLICY
HOMEOWNERS NAME: fi e
ADDRESS:
/ �
lf�j Y �>
REROOFING COMPANY NAME: /� e
APPLICANT'S SIGNATURE: —
CITY OF CUPERTINO
BUILDING DEPARTMENT
•. Reroof/winword