R-3550 r M
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 3550
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228
'ED D N S FROM LAS PERMIT ISSUANCE OR
180 DAYS FROM LOST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
21751 Santa Bella Place _ RESIDENTIAL X COMMERCIAL OTHER
OWNER'S
ROOF
NAME Neil J. Laird FIHAZREARDOUS COVERING
AREA CLASS
ADDRESS
21751 Santa Bella Place, Cupertino EXISTING ROOF COVERING
PHONE 408-725-1738 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S
NAME Security Roofing, Inc. TO BE REMOV ED 1 RETAINED 1
TYPE OF ROOOFF COVERING
ADDRESS P,P. 0. Box 2450, Menlo Park, Ca. 94026CITY& EXISTING
PHONE 408-947-8811 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER 25684 WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 fcommem
cin. with Section ]000) of Division 3 of sena Businen and Prof„•ion.Code, WOOD SHINGLES
and my licc.n„ u I force and affect.
License l eJ� Li..Numb.,-306844
Daa Contract., ng, I ic OTHER (SPECIFY)
OWNER BUILDER DECLARATION A / p�
I hereby affirm that I am exempt from In.Con[ncmh License Law fPROPOSED C/
Me following reason. (Sec. 7031.6, Business and Pro...ions Code: W
Or county which requires a permit to construct,alter, improve. OIiM,°r
repair ane structure,prior to its issuance, also require•the appy r such gUl LT-UP ROOF R 14 19
permit to file a signed statement that he a licensed pureuan Man mmis
of Me Contnmorl License Lm Itnaptar 9 (commx "tea c o 00) /
of Droition3o+the Business and Proe„.m or That
h. a in pHA LT SHINGLES yVf-
M1am and Ma D„i• for ma alleoed axe Psion. Any violet r 6e=tion tltl'�
7031 6 lar enr applkam m.a permit u t•me eTiplican it panatr ffrtV
of nm mon M„five hundred dollar•IS5 S°I: WOOD SHAKES
❑ I,a•owner of Me property, or my mployses wi as e•Me
comps„ation,will do Ina work, and the st cturo o intended f r VV00D SHINGLES
for tele ISac. ]040, Bwinan end 'r
for od ontrac se
Lew tl°„not apple 1°an owner of property no ui or improv
and who do„Such work himself or through his wn ass,or he,
such improvement. are not intended or ono for se 11, however, M OTHER (SPECIFY)1/2'I Id
building or improvement is sold within ono ya of Co tion, the own
builder will have the burden of proving that he d not b Id or improv for Pres i ti que ETR ass A
°”'°°'°°"°'°) PROVIDE I.C.B.O. REPORT NO.
❑ I.
of the property. a xc luaively n[mcting wit enfetl
comnc,on ,o comvucl M° project San. 1044, B and rofeasions
Coda: Tha Cony„tot• License Law does nol eDo v to,nntow of property PROVIDE III INSTALLATION SPECS.
Who build• or improve• In...un. and who contra•for rojects with a
contractor(s)licensed pursuant to In.Contractor's License Law.
❑ 1 am exempt under Sac. ,B.d P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Building 114.00
1 hereby affirm that I have°c...i+icete of consent to salf�ihsun,o
tific. of Workers'C pan[t°1i°n Insurance,ora cerlifi d Copy thereof(Sec. Seismic �00
Policy
La°.8850285-90/npany State Worumn Carp. Ins. Fund 3/13/95 $8,000.00 V
Policy No.
Certified copy is hereby lornien d. r Total 114.80
Canified copse is d n In:<i!v inwaklion tlivif�
Applicant
+4- AU T
CERTIFICAT F EXEMPTION FROM WORKERS' N.C. 0 PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE \•�J/�/�/�/�J�
(This section need not las completed if Me permit is for one hundred tlaL
Are(SIM 001 or 1„a.) J
I certify Mat in Ma performance of any
work for which this permit is /
to the Workers'
not ampbV any pawn in any manner so as to become subject S
to the Workers'Gompanxtidn Laws of California.
NOTICE should
APPLICANT: o atter making this Compensation
p of Eons of on,
you sh Cold become subject ei the Walkers'h such provisions
provisions a the
Labor Coda. you mon for<hwith comply with such provisions or [M1if permit
.Fall be d„matl rrvaketl. All roofsshall be inspected prior to any rooting materialbeing
I certify Mn I nrv°r„d[his application end flet.Met the above informs Installed If a roof Is installed without first obtaining an
tion is Correct. I a.r„ to comply with all city and county ordinances and inspection,I greeto re ova all ew materials for inspection
alta laws relating to building construction, and hereby authorize repro.*.
,.fives of this City to enter upon the above mentioned property for inspection
pu.posef.
IWt liabilities.a.r„ ova, indemnify antl bap M1u hich the City of Cu Partin. O
against id iyi consents,Costs and gr Ming whin may it.MY way aCCrue '
against said Clry b ronwagen=e o+me granting of this permit. SIG URE 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_ ___
• SUBJECT: REROOFING POLICY 1 OR TIIE CITY Of CUPERTINO BUILDING DEPARTMENT
PRIOR'I'O ISSUANCIi.OF 1'IiRMfr AND INSPECTION PIIASE.
I. Prior to permit issuance, you 1111151 agree (o comply will, U.B.C. standards 111d manufacturers spec's
ou reroofing.
2. New roof coverings shall not be applied rrithou( first obtaining all inspection and wrillen approval
flour the building inspector. A final inspcclion and approval shall he obtained from the building
inspeclor when the 'emoting is complcled.
7. All types of tool-511,111 be inspected prior to any lootbcing installed.
4. In mdcr to leccive a fim11, yon 11iost complete steps I, 2, and 1.
I,) Prciuspeclion or (car off approval.
2.) In plogress inspection approval.
J.) Final inspcclion approval.
a.) Operrblcsntolcc(Icleclorvclificalion
• b.) Spade arrestor inslallalion
5. If plywood is installed, a plywood nail inspection is requited.
G. If any roof is applied "'11101" Fist obtaining an inspcclion, you will be required to remove all new
material down to the shcathiog and a building inspector will inspect all sheathing at (]Ill little.
WE UNDERS'T'AND THE ABOVE POLICY ON ItEItOOFING AND WILL COMPLY Wrrll TILE
POLICY /VF- Z ��
-D
IIOML•OWNERS NAME:
J , l r���
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
J �
CI'T'Y OF CUPERTINO
BUILDING DEPAR'I'MEN'I'
•
Rcroofhvi mvo l d
• CjfAj Of C"perli11O
P.O.oo.Soo
10300 loi to Avenue Cupertino,CA 95015-0500
Cupcninn,CA 95014-3255
lclrphonc: (400)252-4505
FAX: (4011) 252-0753
COMMUNI TY 0rVIaOPMCNT
SMOKE DL"I'LC'1'OR CER-I1171CATL OF COMPLIANCE
I understand and comply with Section 1210-a of the Uniform 13""d"19 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 arca giving access to room used for sleeping
purposes. 11-existing smoked deleclors comply, no new detector shall be required.
• 1 understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADMIM:
�z - 3s5o
1'LRMI'1- NUMBER:
IIOMGOWNERS SIGNATURE;:
3It 271 s
DAl'L:
winwordlsmkdet
•
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