R-4124 APPLICATION FOR CITY OF CUPERTINO N� IUMIBERR- 4124
INSPECTION 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
1�47 ' RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
NAME `J ��� M��� FIRE ARDOUS COVERING /J
AREAy CLASS /Y
ADDRESS �0.7.Z� r/ ?o�.�� e EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S TO BE REMOVED 1 TO BE RETAINED
NAMEL �J++ TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP y6T,lgi6�a/a�OK. -G 40 _4i,,
/af.� EXISTING
/yqF�
PHONE „Z 6/ _JJ BUILT-UP ROOF
�E
LICENSEASPHALT SHINGLES
NUMBER S�'ry,� WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provision.of Chapter 9(comment WOOD SHINGLES
ing with Section 7000) of Division 3 of the Business and Prof ..ions Code,
and my license is In full force and affect.
License Clens Lie.Number
Data Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
1 herby affirm the, I am evmpt from the Contractor's License Lew for PROPOSED
The following reason. (Sac. 7031.6, Business and Professions Code: Any city
Or county which requires a permit t0 construct, altar, Improve, demol4hor 1
repair any structure,prior to its issuance,also requires the applicant for such gUl LT- OOF
permit to fila a signed statement that he is licensed pursuant to the provisions
Of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) aS P4 r li�9F
m Divi.ion 3 of the Business and Profession.Cod.)or that he is exempt there ASPHALT SHINGLE y
from and an basis Ins the alleged exemption.th Any violation of Section a
from a d any applicant for a permit the applicant to a civil penalty f
of no,more that five hundred dollars(9500).): WOOD SHAKES
❑ I,as owner o1 the property, or my employees with wages as their sola
com pantaloon, will do the work,and the structure is not intended or offered
for sale(Sec. 7044, Business and Professions Code: The Contractor a License WOOD SHINGLES
Law does not apply to an owner of property-no builds or improves tnaraoq
and who don such work himself or through his own employees,'Provided that
busuch improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) qq
ilding or improvement is sold within one year m completion, the owner p 1995
build., will have the burden of proving that he did not build or improve for
purp.n.I.M...). PROVIDE I.C.B.O. REPORT A
❑ I, of the property. em exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Cod.; The Contractor's License Law does not apply to an owner of property J I J I INU
who build$ or improves Thorson, and who contracts for such projects with a PROVIDE III INSTALChI�IOf�V
contractora)licensed pursuant to the Contractor's License Law.
❑ 1 .m exempt antl.. see. ,B.aP.c.for his
aeon APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION Building
I hereby dfirm that 1 have is certificate of consent to sell Insure,
tificne of Worker' Compensation Insurance, acart i}ac.PY moll ea Seismic
3000,Lab.C. Ili I �/$ S/J/QO 6 •(p�
PolicBy C.1 f�� /y I.h Company J /�h C n �N 6/a/ / /]p
c..",ied copy Hereby furniahad r Total (b/
c..tined copy P>`✓ it1�.�we mvisio
Applicant r
CE KATE OFeXEMPTION FROM WORKERS' N C O PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred doh
In.($100)or lass.) - P
1 cattily Snot m the performance of the work for which this permit i. �/✓�r
issued, I Nell not employ any person in any manner to as to become subject 7/
t0 the Workers'Compensation Law.of California.
Det. A00li4nt
NOTICE TO APPLICANT: If, after making this Certificate of Exemption.
YOU should become subject t0 Na Workers Compensation proviso On.Of Na
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being
shall be domed revoked.
I certify That I have read this application and state that the above informs installed If a roof is Installed without first obtaining an
flim is correct. f ear« to comply with all city and county ordinances and inspect' n,I fee to remove all new mat@rlala for insppction.
.tate laws raining to building construction, and hereby authorize represent J
ipo of this city to anter upon the above property inspection
purpose ..
/ l/ /I -
Purpota.. /J//
Ilya) agree s. wve, indemnify and expenses
harmless the City of Cupertino
against liabilities, cons judgments.cels and expanses which may in any way accrue SIGNATUR F APPLICANT DATE
against said City in consequence 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
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aril approval shall be
ba,pection obl"aliTed [rcua Ule .
VIhen UIe res:ooLiJx) is crnnpleteci•
All LYPe5 v[ roar . shall be i�Tspectgd pt�or p WAY iooP be�1xJ
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A. Tlr ordcl Lo receive a [incl, you unJst ca„plete sEep9 1, 2,
1, ('J:ei115pectioll approval
2. Iliproyress 11AspectiolT approval
7 . l'iJTal iJvpection approval
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b. Spark aJ reslor iJAstallatlon ot�oHr Y4 Hlii
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retrgvo all new n,atel ial dowslT U,atto �H3119. t1JT9
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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 on the ceiling or wall in 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:
HOMEOWNERS SIGNATURE:
DATE:
\� winword/smkdet