R 2961 APPLICATION FOR CITY OF CUPERTINO N MBI R R 2961
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 _
HAZARDOUS ROOF
NAME VYII, FIRE COVERING
/1 AREA CLASS'
ADDRESS S EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
TO BE REMOVED - TO BE RETAINED
.. NAME":!;j.�L' 6 9Q ^ VLA TYPE OF ROOF COVERING
ADDRECITY 81 ZS(' XJJJ 11 J�C.Lt ( Yn .
EXISTING
PHONE_ZZJ-9G.(n3 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER Z Z8 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hegbY affirm the,I em licensed under provifionf of Chapter 9(commem
inp Wien Section 7000) of Dimalon 3 of the Business and Professions Code, WOOD SHINGLES
and my Ilcon if fWI fief.and effect. O
Licanu su LIc.Number M
one Contractor F 9 OTHER (SPECIFY) P IA. I
OWNER-BUILDER DECLARATION
I hereby affirm In at I am uampt from the Contractor's License Lew for PROPOSED O If1(1�
the following reason. (Sac. 7031.8, Business and Professions Cede: Any citymSEP O 1J.7
or county which requires a Permit to construct, alter, Improve, de
olish.Or V
r.palr any structure, prior to its Issuance, elan requires the applicant for such BUILT-UP LT-UP ROOF
Permit to lila a signed statement that he is licensed pursuant to the provisions I tie
of the Contractor's License Lew (Chapter 9 (commencing with section 70001 C(IY Ur L'Urrn�
fromDivision 3 01 the Business the end Pro,.d x , Code)or y v of iti exempt them ASPHALT SHINGLES
Irons mtl the befit for the alleged exemption. Any violation OI Section
7031.8 by any,t five ant lore permit subjects the applicant to a civil penalty
Of not more twee five themed ertlen r MYol.h WOOD SHAKES
[] I, ti owner of the property, or he employees with tepee as their sole
for sa[a (Sec.
will do the work,and the structure is not intended ' License
for sale ISec. apply Burmah and f property
Code: TheContractor'srnpr oor9 thereon, WOOD SHINGLES
Lew does not suchapplto an owner of through
who builds or ibs, evesded that
and wwo no
such work himself Or through tie Own employees,If, however,
that
such improvements improvement
ere not intended or n. Va. for foe. If, n°thew the OTHER (SPECIFY)
building or improvement if sold proving
One yea, of of completion, the owner
purpose
will have the burden of proving the\he did not build or improve for
oh'[3 , a sale.).
PROVIDE I.C.B.O. REPORT NO.
I, . st the property, em exclusively contracting with licence
convectors C construct the project (does
not
Business nee and. f property
Code: TdO Contractor's thaenae and who cot tracts foauch pr of with a PROVIDE MFGR. INSTALLATION SPECS.
wno builds )I Improve therat n, end who contracts for such projects with e
cont] I am licensed pursuant ant m the ComrectorY License Low.
� I am exempt under Sec. ,B.&P.C.for this
rai APPLICATION DATE VALUATION PERMIT FEE
Owner Do,.
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to selhinSure,or a cer 6
tificata of Workers Compensation Insurance,or a certifi.d copy thereof(Sec.
3800. Lab.C.). "-- SEISMIC
1 V
Policy No. Com pent/ ��Z / e�
e
Certified copy is hereby furnished. l
Certified copy if filed with
he Ci\y inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT VALIDATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dab
ler.IS 100)orn
It.)
I certify that in the performance of the work fol which this permit is
issued, I shell n0\employ any person I.h any manner at as to be ° eau b
to In or ar mpenm[i on Laws
..
Data
NT:ApnIf,
N OTIC TO APPLICANT: If, aM1
er male t a Cert Hipate o Exemption,
you should become subject to the Workers C 6ansailim Provisions of the
Labor code, you must forthwith comply Witn ch provisions or this permit 'All types of roof shall be inspected priorto any roof being installed.To
,he be learned that
rI haed. receive a final I am aware there will be three approved inspections:
is c rV twat I neve rend this comply
with
of and nate that the above Informed Pre, In ro ress,and final. If roof is applied without first obtaining an
tion is correct, I agree m comply ct ah city and county ordinances and P 9 PP 9
stet•s of misting to bullring construction, and hereby pr authorize for sp[tion inspection, I agree will remove all new material for inspection.
puivef 01 this city to enter upon[M1a above-mentioned property for inspection
pu.(We)
(We) spree \o Gave, indemnify and keep nermlefs the City °f Cupertino
y apeinst sold City i judgments,costs and granting
Mich mem in any way
accr o
epainrt stir City in consequence of Na granting of this permit Q�-<Jj
SIGNATURE APP NT DATE
r REQUIRED. PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION - -
INSPECTIONS INSPECTOR Di INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
INTEGRITY ROOFING
355 Colville Drive
San Jose, CA 95123
R (408) 225-9263
I.ic.1 626228
OVEfM FFD=
1. II113EUM S HUZ IAF FOR ANY M=G OR IV4M WOM.
2. REHA[ID MI93M S USiFS.
3. Crim MOD FOR ANY LRY IYIP A%RPD ALL PE FMM.
4. INSTALL UMUY FO:PD AS1M FELT CIM HMM FICCF 3RD.
5. INSTALL ALL NEW PIFE, JACKS, ADD MWL VNIIff.
6. IDSWL MEM IIUP EII£ON ALL MTS.
7. WDEL S1A W CCL2 IN ALL EAVES.
8. IDSIAiL FQRIY YEAR FIR 024USrrICN SIIDIIFS OVER FELT.
9. INSTALL Z4= IN ALL LMES.
10. ALL ANNE DISD r MM HUMIR ES ARE IN AC131MU WlIti 1CM IUM.
INFLUX suff4 inD,
HSI=ALRRESS: JAI(Ragwm
79E5 F[NFION Cr.
CIFERM, Ch.
95014
chit of CiVeftlAd
p.o,Dox Soo
v17001one venue Cupeilinu,Calllornh 95015 \
Telephone:
ne, Callon 2 4501A
7ulephone; IA001 252-A505
DEPARIMEN i OF PLANNING AND DEVELOI'MEN f
sUL17CCi: SMOM DI:IEM'OR CII7TITICNIZ Or Ca tL-W19C
I mdersLami and agree to ccWly wiUl Sect.loii 1210 of the Uni.fonn Building
Code.
Section 1210 requires when repairs to a k;itxgl'e family dwelling exceed-9
$1,000 a smolm detector will be installed iitouhW on the ceiling or Wall
at a point centrally located in t11e corridot bt area giving access to
no
Looms used ,for sleepitlg purposes. If existi-4 crooks detector coW
new detector shall be required. ,
I mderstalxl. the above requirement atxl cerrity that W now have smoke 1
detectors installed that do coWly.
AD=S R�g185 �urrt k;n oar
PL11MI•l' NUM1lM: `
1'IGMWgNIzS SIGNMURG:
smokedeto(B-1)
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