R-3984 PERMIT R_ 3984
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408,252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
BUILDING USE
to 1 k RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME A�'1!l 71-049 SQC FIRE D
COVERING
AREA CLASS
ADDRESS EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOjf '.S—
A P 5�1` �` TO BE REMOVED TO BE RETAINED
NAME `I1 \_�'� A TYPE)DF ROOF COVERING
ADDY
CITa SS
IP �� V�ti t"�. l-� EXISTING
PHONE q b 3 4h BUILT-UP ROOF
LICENSE :PtROPOSED
LES
NUMBER
AKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am litmus linear provisions of Chapter s ons Code,
cine suites Section full of an don 3 of the Business and Professions Code, IN LE$
and my Cienu if In lull torts and effect.
Salines clan Contractor
PE FYIAll
Dote Comracwr
OWNER BUILDER DECLARATION If
I hereby affirm that I em exempt from the Contractor's License Lew for IM following reason. Ise<. )0]1.6, ensinafs antl Pmbesions Catle: Any city
or c unty which requires a permit t0 construct,alter, Improve, 0emolish,Or
ripe,any structure, prior to its issuance, also requires the applicant for such permit to 'I.a signed statement that he is Iicansed pursuant to the proviflonsofhe Contractori License Law (Chapter 9 (commencing with Section)0001Lero+ Division 0 of me Business end Professions Code?or that ate is exempt mare SHINGLE �'{�
N berm •ata the basis for the aliens exemption.the
Any ant to
Section
)031.6 by any th t ive hu for a permit subjects me applicant t0 a civil penalty
or not mora met five the property,
dollars r my e.): $
I, ti owner OI ma property, or he smpture is with wages as Mair fold
,or
(Sec. will do thesin work, and ma structure is not intendedntrto 's offeree
for lila (Sec. 7044, euansf andnet f property Code: The Contractor's License WOOD SHINGLES
Lew woes not apply to an owner o+ hr property who builds to improves maroon,
dna who noes ant work himself or ed or offered niown amalle. 11, provided that
wan ng or iamrov ere his ;Manses o. neyfor fele. It, however.hownerthe OTHER (SPECIFY)
buil dery or have Pyemia 'd sole within one veer of complexi or ma
builasr will have the burden of proving that he did not build or improve toe
P of PROVIDE I.C.B.O. REPORT NO.
I, as owner of the property, am exclusively contracting with licensed
ontra< n to construct the project (Sec. )044, Business and Profession$
Code: TheContracm:sLicense Law does nmapply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mprovas thereun, and who contracts for such projects with e
contrw tor(s)licensed pursuant to the Contractor's License Lew.
On m
I am exempt ands. sec. ,B.aP.c,for i`
tea PPLICATION DATE VALUATION PERMIT FEE
Ow Date
her WORKERS'COMPENSATION DECLARATION 1Ag� Buildin ---r.---
I hereby affirm that I have a certificate of consent to self insure,or a car �e''(L/MI�
tificeb of Workers Compensation Insurance,or a certified Copy thereof(sec. fill�� Seismic
3800,Lab.Cd. �Y C/p
Policy No. Company �
8 Certified copy is narabv tisn.a. LUN 000
Total
Certified copy if filed with
t oath city impaction division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PE MIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section nue not be completed if the permit if for one hundred sol-
Ian If a00)or that
i
I certify Inst m tate ,any Person
of the work for aswhich [ria permit if
iouee, I snail not employ ion Lenon In any Manner so as to become subject
to the Workers Compensation Laws of California.
Data AT: If,
NOTICE should
APPLICANT: o he Workers'making this Cartiensati n p of Exns ofithe
Lau moats b coma subject w the mply Comph such provisions
ns or ham of ma
Labor Code,vera moot forthwith comply with such oroyiaon.ar this permit All roofs shall be Inspected prlorto anytoofing material being
shall has seemed revobd.
I certify that I neve read this aopllution and stat.mat the above inlorma Installed. If a roof is installed without first obtaining an
non Is correct, l tarn to comply with all city and county ordinances and ins, I I agree to remove all new materials for inspection.
mu laws relaxin, xo building construction, and narabv autho rice npresem
tatives of this city to enter upon the above-mentioned property for inspection
purPo.ef. Z
IW 1 eprse to live, indemnify and keep harmless the City of Cupertino
against Ilabilities,judgments,costs and expenses which may In any wry etcrw
against Said City in consequence of the granting of this permit SIGNATU OF APPLICANT DAT
PRE-INSPECTION: PLYWOOD: It
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 POR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
L Prior to pennit issuance, you ums( agree to comply will' U.B.C. slaudards and manufacturers spec's
Oil retooling.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final iuspectiou and approval slmll be obtained from the building
inspector wlren the reroofing is completed.
3. All types of roof shall be inspecled Prior to any roof being installed.
4, lit order to receive a final,you must complete steps 1,2, and 3.
l,) Preinspection or tear off approval
2.) In progress inspection approval.
• 3.) Final iuspectiou approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
G. Ir any roof is applied without first obtaining air iuspection, 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 'PILE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
IIOMEOWNEItS NAME:
p.lM LL v r r �v� S
ADDRESS: l7 -A n ��
REROOFING COMPANY NAME: Dg
APPLICANTS SIGNATURE:
• Cfl'Y OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword
I
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Citta of Cupertino
SMOKE DETECfOR CERTIFICATE OF COMPLIANCE
1 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 sm Ike detectors
installed that do comply.
ADDRESS: I o �0
PERMIT NUMBER: rz,— 3 ci 8
HOMEOWNERS SIGNATURE: —
DATE: Z k Si
I
winword/smkdet
I
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