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R-4002�� OFFICE COPY _ _ _ PERMIT R- 4002 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT ,INSPECTION DIVISION PERMIT EXPIRATION T EXPIRES IF ED (408) 252-4505 EXT. 228 WIPERMIT ENOT THIN 180 DAYS OF PERMIT ISSUAN OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS - BUILDING USE in CalisFow\`�1 RESIDENTIAL COMMERCIAL OTHER OWNER'S ��j( HAZARDOUS ROOF NAME '10 QUt%I,/ FIRE COVERING AREA CLASS 1— EXISTING ROOF COVERING `J �I3 e�--VW ADDRESS �� t C -0,5 p NUMBER OF EXISTING COVERINGS PHONE ZS — O TO BE REMOVED TO BE RETAINED CONTRACTsix O^R'S"`Q (a (=• ✓1'LOOR`� NAME /-�G., � ti/S R.nOF �`^'C TYPE OF ROOF COVERING ADR iib zt O 3 Yrti'16&IPL F!,—Ld. S C • EXISTING (o9-7'�—,5,6 BUILT-UP ROOF PHONE ASPHALT SHINGLES LICENSE Z �i NUMBER WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby 01th that I am licensed under provisions of Chapter 9 (comment Professions WOOD SHINGLES ting with Section TOW) of Division a of the Business and Code, and my license I. ir�f till . end affect. / f 1 UZ 1 D.t nse Clm ConN�or" to OTHER (SPECIFY) �1LLY3YL 1 S, w RATION Oat I am from the License Lew for nowin affirm that a.5 031 .5,8 from ,he PROPOSED dContractor'ssion Code: Any city the following rondo. (Sec. c nass end Plter, i permit, to pr county Wnlctl requiresior a permit [O construct, altar, the demOliauch aOve, re prior m its ifsuen Hao requlraa tna e r such repair any rte 'a BUILT-UP ROOF permit to ills a npns0 statement toot tea i• licmud our • [o ane prom a sign a 0f the Contractors License Law 'Chapter 9 Icommenc with Section 7000 of Division a of the Business and Prores.mm cod.) o. tI [ he n...mpt the,. ASPHALT SHINGLES from and the bans for the essayed ..emp,ion. A violation of -,.!on Itpli<en[ [o civil penalty 7001,5 by env applicant ,or • permit mbjecb r of not more That five hundred dollars (5500).1: WOOD SHAKES ❑ I'as owner o, the property, or my amps les with way • their •OI ( compention, will do the work, and the ant, sere is n I d or 1<,}�9�.1 sa for fele (Sec. 7044. Business and Prof eolo Code: Th. t ctor,, Li . WOOD SHINGLES Lew dox not apply to en owner of prop ty who builds or 1 rove• that Co ♦/ his and who does such Work himself or tell yh own m as, 0,.videdalh•t improvemenn are not intend or oflared ,o If, pa w�j the OTHER (SPECIFY) Buch ilding or improvement Is ml "thin one at plar.n, wrier builder Will terve tn. burden of roving that h o[ 0� prove f atyp Pulp....1•ale.). PROVIDE I.C. B.O. REPORT NO. ❑ 1, es owner o, [he propert am a3clyu on,, ti with lice ed contractors to cnn...[ Ne prolac (Sec. and Prole tons C, .nown., o, W party Code: The Contractor's License Law as no, app ,an PROVIDE Ill INSTALLATION SPECS. who build• o mprove% thereun, and w o contract , such Project with e contrech.r(s) licensed pursuant to the Cc rector's License Law. tee❑n I am e..mct untlar Sec. ,B.&P . for coif pPLICQ7ION DATE VALUATION PERM.LT.FEE Own., Dat. WORKERS'COMPENSAT ION ECLAR-T-ON Bulldl hereby etfi,r that I have a cariilicete 0 consent t0 •a �in•ura, ora ter ti,ic I. of Workers Compensation Insurance, a cer,iliad dog thereof Mist. III�� RAR 6 Seismic ]800, Lab. C.). 199 Policy No. Company Certified copy is hereby furnished. 8 Certified is tiled the inspection division. (]�' Uf ` 1r L J—� Total copy with city (/Y't l v APDIic•gt CERTIFICATE OF EXEMPTION FROM WORKERS'N D ❑ PERMITAUTHORIZATION DATE COMPENSATION INSURANCE (This sanction need not be completed i, the permit is for one huntlre0 dol len ($100) Or I certify that in the performance of the work for which Ihif permit is noel n toted, 1 shall not employ any Lenon in any manner so n to become sublet, to the Wo'kari Compensation Laws of California. Den Applicant NOTICE APPLICANT: attar making this Certificate on, of Eons You should become subject o the Workers' Comph p of Me nsoviaihis a such provisions Labor Code, you mon forthwith comply with such provi•io.. or this permit .Cod i All roofs shall be inspected prlortoany roofing materiel being Snell be deemed revoked. Installed. If a roof Is Installed without first obtaining an I <•rtify that I neve rend this epLliu[ion end state that ,be above informs ,Ion is correct. I agree to comply with au city and county ordinances and Inspection, I agree to remove all new materials for Inspection. Flat. laws relating to building construction, and hereby authorize represen .vives of this city 10 enter upon the above mentioned property for inspection pulp...•. (We) sip. to me, indemnify and keep n•rmleas 8n. City of C.P.,tino ♦ Q�`��L✓°^I� against liabilities, judgment•, cost, and saneness Which they In any We, accrue 1fg?6NyIJRff OF 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 _ _ _ SUBJECT: REROOFING POLICY POR TILE CITY OF CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PERNBT AND INSPECTION PHASE. 1. Prior to permit issuance, you Illus( agree to comply with U.H.C. standards and manufacturers spec's om reroofing. , U 2. New roof coverings shall not be applied without first obtaining all inspection and written approval !four 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. Ill order to receive a final, you must complete steps 1, 2, and 3. 1,) Preinspection or tear off approval. 2.) Ill 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. G. If miy 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 IIOMEOWNERS NAME: — ADDRESS: REROOFING COMPANY NAME: APPLICANTS SIGNATURE: • CITY OF CUPERTINO BUILDING DEPARTMENT Rcroof/wimrord tout 6,0s,� f 10300 Torre Avenue Cupertino, CA 95014 G p< rttr o Building Division (408)777-3228 (408) 777-3333 (fax) WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: --1 have and will maintain a certificate of consent to self insure for worker's compensation, as provided for --I have and will maintain workers' compensation, as required by section 3700 of the Labor Code, for the performance of the work for which this permit issued. My workers' compensation insurance carrier and policy number are: (this section need not be completed if the permit is for $100.00 or less) is --I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so at to become subject to the workers' compensation ovisions of Section 3700 of the Labor Code, I shall forthwith comply wi h those rovisions. Date Applicant: f� by Section 3700 of the Labor ode for the Performa e of e work for which this permit is issued. • WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. Ponied on Hoc, ycLal Popo 0 • LJ 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 for sleeping purposes. If existing smoke detectors comply, no new detector shall be required. 1 understand the above requirement and certify that we now have sI mke detectors installed that do comply. ADDRESS: PERMIT NUMBER: HOMEOWNERS SIGNATURE: DATE: winword/smkdet I