R-4137 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4137
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 r BUILDING USE
35(5 G1nO 2.2. C1 L�T RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAI
ROOF
NAME ,r' `� ' `� 'rS Mia FIRE COVERING COVVERING
1 Q, AREA CLASS
ADDRESSI n� ;2,4J? — E) STING ROOF COVERING
PHONE OS v3 NUMBER OF EXISTING COVERINGS t
CONTRACTOR'S
�)p r�� TO BE REMOVED TO BE RETAINED
NAME 0.Vl
to ' eMDD.w�I TYPE OF ROOF COVERING
ADDESSC
CITYR&ZIP -5 -7� .J�' EXISTING �(
PHONE CJ7I — 7500 BUILT-UP ROOF
LICENSE45 20 1 O ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commons
..no with Section 7000) of Division S of the Business and Professions Code, WOOD SHINGLES
and mY license is in i p and effect 20 Q
License
av a Ole Conneceurer !11e� OTHER (SPECIFY)
II'' OWNER BUIL DER DECLARATION
1 hereby effirm that I am exempt from the Contractor's license Law for PROPOSED
the fallowing meson. Box. 7031.6, Business and Professions Coda: Any city
or countytr
which r•qui as a parmit to construct,sitar,improv, d.n ith,or
..Pair.nVv ihcth..,prior to It.Is.uanc. also requires the applicant for Such BUILT-UP ROOF
permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter f...io s (commencing with Section I7000)
n.,.
of m anon 0 clothe Business me Prolusions coal o,mss he ti exempt[neon ASPHALT SHINGLES
from dna an tresis for the alleged rmi exemption.the
Any violation of Section
of no by any applicant hu fore permit subjects the epplicent to a evil penalty
of not more that r of the Pro dollars r in, a l: WOOD SHAKES
❑ I,ti owner of the property,o he employees with wends e,men ems
compensation(Sec. will do th.work, .norm.structure i.not Contractor
ots t or License WOOD SHINGLES
for
sales(Sec. )044, to an
and f property
Cotler: Tice or mprove% license
Lew woof not such t0 en own.n of through
sewer n em to i es, Overs thereon.
she who,. such work nit elfint On ed or offered his Own r sale. If,providedvetl\ha\ M,_.,_,,�f'g/g�n
sui insplov.mrov era not ipbmee o. eyfor sale. n, nothevar, the OTHER (SPECIFY) M`^""� �l
bus idling or improvement i sold ovinia one year of ct build oar, p owner
builder will neva me burden of proving that ice did not build or improve for q�
Purpose of sale.). ' PROVIDE I.C.B.O. REPORT NO. 3r ( 2
❑ I.
as owner of the property, am exclusively convecting with licensed
contractors to construct the project (Sec. 7044, Business and Processions
Coca: Th Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve thereon, and who contracts for such projects with a
contractor(O licensed pursuant to the Contractor's License Lew.
reap^1 am exempt ghee) sec. ,B.&Pott for anis APPLICATION DATE VALUATION PERMIT FEE
Owe, Date p
WORKERS'COMPENSATION DECLARATION P Pq I Buildin�
1 hereby affirm that I Compensation
i nInscertificate 1 ra coni to self-insure,rvr•,Lr scar �p
ofreefs of Workrm hat I havea Inw.aor cent to se.of-insure dot(Sect Nor $e13mIC
0800,Leb.sir — 5+a 1 W `Ar UN 21 9
Policy No.O Company __ 1
8 Cdnvfi. n...by ser renal. 96 Total
cart as c .Rlee wrt i N tion division.
Applicant ems% CI/ f
CE IFICATE OF EXEMPTION FROM WORKERS' N.C.❑ .[JIIT AUTHORIZATION----,, DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol.
Ln(f1 DDI l
or lai
e tify mlet n the performance of the work for which This permit h
issued. I shell not employ any person in any manner so as to become subject
to the Workers'Compenutlon Lew.of Celitorni..
DataApplicant
NOTICE TO APPLICANT: If, Plus, making this Ce flf cote of Exemption,
you thou Id become subject to the Workers' Compensation provisions of the
Labor Code. you must forthwith comply with Such provisions or this permit All roofsshall be Inspected prior to any roofing material being
shall be deemed revoke t.
1 certify that I have rete This.PPlii..I.n.nd.1.1.That The.nave informs installed If a roof is installed without first obtaining an
tion I. correct I adrse to comply with an city and county ordinance dna ins I agree t0 re OV II new materialstor inspection
ebb laws relating to building construction, and hereby ether riz• rdpreem
btives of this city to enter upon the above-mentioned property for inspection
Purposes. A� I `S
)We) erre seaharmless ver, indemnity entl keep nermlthe City of Cupertino
against liabilities,judgments,costs and expenses which may in any my a-crus
against aid City in consequence of the granting of this Permit NATURE OF APPLICANT ATE
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 THE CITY OF CUPERTINO BUILDING DEPARTrbIENT
PIUOR TO ISSUANCE OF PER1,11T 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. Netiv 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 ally roof being installed.
4. In order to receive a Final,you"lust complete steps 1, 2, and 3.
I,) Preinspection or tear off approval.
2.) In progress inspcction approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywuod nail inspection is required.
G. if any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to lire sheathing and a building inspector will inspect all sheathing at Wat lime.
WE UNDERSTAND THE A13OVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
IIOIv1EOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAVIE:
APPLICANTS SIGNATURE:
• CIT-Y OF CUPERTINO
BUILDING DEPARTMENT
Remof/winword
AMLIA
CitVjof 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
• point centrally located in (lie 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 stn Ike detectors
installed that do comply.
ADll1tESS:
-2---2- 356 2 -7 �,o-nc�na
PERMIT NUMBER:
Y/�/J /
HOMEOWNERS SIGNATURE:
DATE:
winword/smkdet
• I