R-4039 APPLICATION FOR PERMIT R_ 4039
CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHI N 180 DAYS OF PERMIT ISSUANCE OR
�• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /�/� X BUILDING USE
10/7�' /" fp RESIDENTIAL-&—` COMMERCIAL OTHER
OWNER'S aPe�+[tiw ) Jk e
/f {7 HAZARDOUS ROOF ///III
NAME C/O L'OI'1 C ✓A-IYI , 7R.0 FIRE &rO COVERIN G�
tS�G- Los 5 1K{ f 1 p AREA CLASS
ADDRESS (,:(,����-�'�/C�� 5032- -2.y ' EXISTING ROOF COVERING
2S
PHONE �,� r _ P NUMBER OF EXISTING COVERINGS
JJ `2 O
CONTRACTQR'S (� (� /�
�(_ „ I I _ TO BE REMOVED TO BE RETAINED
NAME i 1�1Cpp.L�rZDG"ti F-'1V1�71"�+C `-O TYPE OF ROOF COVERING
CDD&ZIfS -1 O O`r l Y�O�✓�G'� (�' . EXISTING
PHONE V I �`� ' `-�'1� • 1 3 BUILT-UP ROOF
LICENSE ' �fo9 1 4,1 /q ��ol7�oASPHALT SHINGLES
NUMBER `
�C
LICENSED CONTRACTORS DECLARATION WOOD SHAKES
1 honey affirm that I of licensed 3 do,of
a Busies of Chapters ons(common
sing suint s.<nan Tool» of Division 3 PI m.Business and wm.won.stiff., WOOD SHINGLES
and my license i n f rte and a"."L 19
LF.n Ian Lic.Numbs.--spz"Ye'r=1� r4 ID
9-.L
Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the fallowing rusen. (Sec. 7031.6, Business and Professions Coes: Any city
Or County which requires a permit to construct,alter,improve,demolish,or
repair any wuctuq,Prior to its issuance, also requires the applicant for such gUl LT-UP ROOF
Permit to file a signed statement that he is lic.nsed pursuant to me provisions
of the Contractors License Lew (Chapter 9 (commencing with Section]000)
oI Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.6 by env ePPHunt for a Permit WbjeCl.me applicant to a Civil penalty
of not mon that Ow hundred dollars($500).): WOOD SHAKES
a 1,s of the property, or my employe"with wages as their sole
Compensation n ill do the work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sac. ]044, Business and Professions Code: The Convector's License
Lew tlon not apply to
an owner of property who builds or improves thereon, I
and wno tlon such work himself or through his own employees,Provided that -T- —TI,
such improvements era not intended or offered for sale. u, however. the OTHER (SPECIFY) �1 s
building or improvement is old within one year of completion, the owner
build.,will neve the burden of proving that he did not build or improve for 1r1�
pulp..." as own PROVIDE I.C.B.O. REPORT NO. 2Z
1, as Owner st the he project
em exclusively contracting with licensed
contactors to construct me project (se<. ]044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE Ill INSTALLATION SPECS.
.no builds or improve$ thereun, and who contracts for such Projects with a
contractors)licensee pursuant to the Contractor's License Lew.
O I am exempt under Sac. ,0.&P.C.for this
reason PPLI TI PI'y
ATE VALUATION PERMIT FEE
Owner era. , ,u-
WORKERS'COMPENSATION DECLARATION ON Build
1 hereby affirm that I neva a ceriif icata of conventent to to Self insure,or a set �]
blit"e of Workers'Compensation Ipayrance,of.canifiad copy tnp,.af($.c. p eR 2e�, 19 r' 'I �7 Q� [�seismic,
3300.Lab. [Vcrycx�y'L�t f IV�L,.In/..lrQl 1. .jY/,`iUl,p Hr ./ (�(
Palicy No. mpany f L p�I-Y1'�I
D Cer00ed moss I.hereby furnished. VUNtCII l VV Total
�C+[lied c fi ed w the City tion division. C1� Uf
Applicant -1- Cates A eS
CE RTI FIC ATEsD4 EXEMPT10 FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE ' I�
(This section need not be completed it ma permit if for one hundred dol.
I...1$1001,r less.1 rr
1 Carllfy that in the performance of the work for which this permit is
issued, 1 Shall not emn
ploy any parson in env manner so as to become Subject
to the Workari Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
YOu should become subject to ma Workers'Compensation provisions of the
Labor Cods, you must forthwith Comply with such provisions or this permit All roofs shall be inspected priorto any roofing material being
shell be d"mad revoked.
1 certify that 1 have read this application and State that the above Informs. installed. It a roof IS Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and 103 tlOflkl agree tlroveAallinemeterialsfor Inspection.
state laws relating to building construction, and hereby authorise represent"lives of this city to anter upon the above mentioned property for ins,"tion /1 ^ _ /�
pu'Iola epna [o saw, inesmnify entl ksep harmless the City Of Cupertino
against liabilities,judgments,costs and expenses which may in any% •ccae
against sere City in Consequence of the granting of this Permit, SIGNATURE CE9APPLICANT 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
SUBJECT': REROOFING POLICY FOR TILE Cf1Y OF CUPERTINO BUILDING DEPARTMENT
PRIORTO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you ,just agree to comply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied tvilltoul first ob(ai,i,g 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. 1,order to receive a final,you ['just complete steps 1,2, and 3.
I,y Preinspeclion or tear off approval.
2.) 1, progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installatio,
5. If plywood is installed, a plywood nail inspection is required.
G. If any roof is applied without first obtaining air inspection, you will be required to remove all now
material down to the sheathing and a building inspector will inspect all slhealhi['g at that lime.
WE UNDERSTAND 771E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANYNAME: �
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
Rerool7winword
_ I
Citil of CNperli"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 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 far sleeping
purposes. If existing smoke detectors comply, no new detector shall be requiIred.
I understand the above requirement and certify that we now have sm Ike detectors
installed that do comply. II
ADDRESS: �� 17L- FO( rt S{-� [a c
PERMIT NUMBER:
HOMEOWNERS SIGNATURE: `
DATE: ✓� `�—
winword/smkdet
a