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R-4134 PERMIT APPLICATION FOR CITY OF CUPERTINO [NUMBERRxis 4134 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMITPERMIT EXPIRES IF (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOU ROOF NAME ACOVERING AREA CLASS ADDRESS 901Zti� 2�Tc-77 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME— TYPE F ROOF COVERING ADDRESSy� y� CITY 81 21b O /l.�/ 5///�--� EXISTING PHONE �, ']�J BUILT-UP ROOF � .L�� / LICENSE !' ASPHALT SHINGLES NUMBER WOOD SHAKES LICENSED CONTRACTORS DECLARATION I herebyaffirm that I licensed provisions of Chapter (common clopWith Section 70001 of Division 3 of the Business and Profession.Coca, WOOD SHINGLES Liceand my licmeeafbcL A2 ..b. es Lic.Number L� OTHER (SPECIFY) Dan Connector C OWNE m....DER from In.RAT N 1 hereby affirm met I(Be . exempt both shed Prof Contractor', License Lew for PROPOSED C or county rep reason. c. permit, o construct,n ane Professions coed: Any city re County which requires • permit to ,alsoralter, improve, eamolis uCh repair any ate a sign,prior to In issuance,h ei also requires the applicant for suns BUILT-UP ROOF b7C!^ permit to Ills a se's Li ente Low that ne r licensee pursuant it the provisions Of the Contractor's Cunene Lew (Chapter 9 Icons)of that with Section there from Division 0 or the Business and Probations tion. or y v he ti exempt coon ASPHALT SHINGLES • from and the beeps for the alleged exemption.the Any violation sof Section ' .1 not o any applicant bre permit subjects Ina epplicent to a civil penalty of not 1,as wee r;ye buses dollars(9600).): WOOD SHAKES ❑ I,a of the property, or he employees not wends m mein sole mpf* (Sic. will e0 sie work, Pr Ins structuren$ odis The ontrded oraclo 's offense for sub (Sep. 7044, to o and fprop property Code: Tha Comprove. License WOOD SHINGLES Lew tloas not apply to en owner or property woo buildsofimproves Hereon, sucandh woo eon such work not int or ed through offered M1is own employees,providedvetl Hn wcn h, or improv ere his ponoses o. neya for eels. If, however, the OTHER (SPECIFY) buildinp or improvement ; sold proving one year of completion, the owner builder will have aM1e burden of proving Het he die not build or improve for Purpose ofssoiW.^e PROVIDE I.C.B.O. REPORT NO. Cl 1, of He property, em exclusively contracting with licensed contractorsto construct the project (Sec. 7044, Business and Professions Code: ThaContractor's License Law does not apply toanowner of property PROVIDE MFGR. INSTALLATION SPECS. .no builds or improve+ theraun, and who contracts for such projects with a cc ntr aC tor(s)licensed pursuant to the Contractor's License Law. ❑ 1 am ...mot under Sac. ,B.6P.C.for this reason PPL17C Act 10N DATE VALUATION PERMIT FEE Ow Det. ser WORKERS'COMPENSATION DECLARATION BUildin *"0I hereby affirm that I nava a certificate of consent to self insure,or a car JUN IJv� tifican or Workari Compsy�/C)It,on Insurancee o certified copy Qo(��Ind/r�a9'�(Baa Seismic Poll, Leb. C 3800, No. ompeny PP�fy /� Aye-Car ed copy is hereby furnished. (n I I Ur soUrthil INV Total 'O Cernfisd copy is filed with the city inspection division. Applicant CERTIFICATE OF EXEMPTIONFROM WORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE COMPENSATION N S URANCE (This section need not be completed it the permit is for one hundred dol. lar+W I00)or Ins.) I certify roar in He performance of the work for which Isis permit is metl, I shall not employ any person in an, m er so as to become subject to the Workers'Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: 11, alter m.kinp this Certificate of Exemption, You Houle become subject to the Workari Compensation provisions of the Labor Code,you must forthwith comply with such provisions pr,His permit 0.11 be deemed eeok.d. All roofs shall be inspected prior toany roofing materialbeing r 1 certify that 1 nava reed this application and stats that the above Informs. Installed If a roof is installed without first obtaining an tion is noose. 1 agree ro comply with all city end county ordinances and Inspection,I agree t0 OVe 811 ew materlalsforinspectlon state laws relation [o buildinp construction, and hereby authorize represam ntives of this city to anter upon the ebove-mennoned property fpr inspection n /+ we) sgree to save, indemnify and keep harmless Na City of Cupertino X// .Xl \ against liabilities,judgment+,coats and expenses which may In any wry accrue against said City in consequence of the granting of this permit. SIGNATURE OF APPLICANT 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 • - i t - I Citij of Cupertino I, SMOKE DETECTOR CERTIFICATE OF COiyIPLIANCE 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 usedI 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 smoke detectors installed that do comply. ADDRESS: PERNUT NUMBER: HOMEOWNERS SIGNATURE: DA'L'E: 1 winword/smkdet SUBJECT': REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT PMOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you umst agree to comply with U.B.C. standards and manufacturers spec's on reroofing. 2. New roof coverings shall not be applied wilhoul first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall be obtained from the building inspector when lire reroofing is completed. 3. All types of roof shall be inspected prior to any roof being installed. 4. In order to receive a final,you must complete steps 1, 2, and 3. l,) Preirrspection or tear off approval. 2.) hr progress inspection approval. , • 3.) Final inspection approval. a.) Operable smoke detector Verification b.) Spark arrestor installaliou 5. If plywood is installed,a plywood nail inspectiou is required. 6. If miy roof is applied without first obtaining au inspection, you will be required to remove all Ilc%v material down to the sheathing and a building inspector will inspect all shcalhiag at Umt time. WE UNDERSTAND TIM- ABOVE POLICY ON REROOFING. AND WILL COMPLY WITH THE POLICY HOMEOWNERS NAIAE: a rv ,c�cT ADDRESS: REROOFING COMPANY NANIE: APPLICANTS SIGNATURE: CI'I-f OF CUPERTINO BUILDING DEPARTMENT RercoU%vinword