R-4653 PERMIT R_
APPLICATION FOR - CITY of CUPERTINO NUMBER 4653
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /Yv 11CM4I w w.
as" � � v/G RESIDENTIAL _COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
VES ❑ I(yes—I understand that a Class A
NAME root assembly is required.
w�' NO Qf Initial I.C.B.O.A
ADDRESS �r��ALL j�`y A G�Ii4I EXISTING ROOF COVERING
PHONE Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME EYF TO BE REMOVED TO BE RETAINED
ADDRESS TY E OFR OF COVERING
CITY&ZIP L
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following 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 B �❑
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions
. of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the r�
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 2�y /�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /�/� "� / 19
a civil penally of not more than five hundred dollars($500).): } i7
E]1, SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will do (AF
the work,and the structure Is not Intended or offered for saleSac.7044,Business and Proles-
.Ions Code:The Contractor's License Law does not apply to en owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.II,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 build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code: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 contractor(s)licensed orsoant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
flm exempt under ,B 8 P.C.for this reason
Data APPLICATION DATE VALUATION PERMIT EE
W KER'S COMPENSATION DECLARATION
by affirm untler penalty of perjury one of the following declaration:
ave antl will maintain a Certificate of Consent to self-insure for Workers Compensation,ed for by Section 3700 of the Labor Code,far the performance of the work for which thistint �s SyG O01mnit Issued.and �Q�f. T 7 Seismic
❑ have and will maintain Worker's Compensation Insurance,as required by Section 3]OO of
the Labor Code,for the pedermence of the work for which this permit is Issued.My Worker's Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person 1n any manner so as to become subject tome Workers'Compensation Laws of Can- All roof. Inspec ed prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the Workers'
r eras'Compensataftion provisioing ns of thelcate of Laborr Code,Exemption,
mustuforthwith become
comply Applicant understands and will comply with all non point
with such provisions or this permit shall;be deemed revoked. source regulatlOnS-
I certify that I have read this application and slate that the above information is correct l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roVenngs to ass"C"or be er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. � �^
spection purposes. C/
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• judgments,costs and expenses which they In any way accrue against said City In consequence
of I O APPLI NT DATE
the granting of this perms.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY __
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: - /
ADDRESS: 91 -7 /41,fV,°,,rs6vI'
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
• Reroof/winword
i
Citsl of Cuing-li O
SMOKE DETECTOR CERTIFICATE Or 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 31,000, 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 sm Ike detectors
installed that do comply.
ADDRESS: X2 2 ' GZ
Lk
PER1v1IT NUMBER:
HOMEOWNERS SIGNATURE:
DATE: 6 2/ 21V-5
. I
winword/smkdet
ctv ol,
Cupertino
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 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: 6 s
HOMEOWNERS SIGNATURE:
DATE: /4o'
winword/smWet
i
Primed on Recycled Po Per