R-3973a
a
OFFICE COPY
_ PERMIT
R- 3973
APPLICATION FOR. CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 ED
IF WERM TORK IS � SUANCEOT TOR
WITHIN IN DRMIT AYS OF
180 DAYS FROM LAST CALLED INSPECTION.
BUI WING All
SS/FjESS _ � l AM pre fVIC 1�BUILDING
l�?`7'1 I!J VJ`�/
USE
!
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
'
HAZARDOUS ROOF
(/'�• p�q)p--�
NAME
"I,,
ARFIRE
CLASS—
}�% 00
EXISTING ROOF C VER N
ADDRESS .
ADDRESS
NUMBER OF EXISTING COVERING
Ln�"�%(J�GJ�
PHONE 1' 0 y—e—
TO BE REMOVED T BE RETAI ED
CONTRACT 'S
////,++•j
TYPE OF ROO COVERIN
NAME `"'�-�
ADDRESS ,f
CITYADD & zip ter
EXISTING v
BUILT -UPR 10
PHONE
ASPHALT SH GLES
LICENSE
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I with affirm that 1 licensed under p'ovi.ionf Of Chapter 9 Icer
c •
0,
ulna with sactlon 70001 • i �.im 3 of he eu.mes o ,
WOOD SHINGLES
and mY license is R'�u 0 affect.
License lass Lic. Number
Data Contractor i
OTHER (SPECIFY)
6 NER BUILDER DECLARATION
I hereby Affirm met I am ..empt from the Contractors L coria L for
PROPOSED
the following ,.non. (Sec. 7031.6. Bu.Iness and Profession, Code: Any city
county which requires a permit to construct, elteq improve, demolish,or
repur any structure, prior to its issuance, also requires the applicant foe such
BUILT-UP ROOF
permit to 111.. signed statement that he is licensed psi r.umt to the provisl ons
of the Contractors License Law (Chapter 8 (commencing with Section 7000)
of Divi.ion 3 of the Business and Professions Code) or that he is exempt there'
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
703 L 6 by any applicant for a permitubjects the applicant to a civil penalty
o1 not more that five hundred dollar. (6600).1:
WOOD SHAKES
(J1, n owner of the property, or my employees with wages as their sole
compensation, will do he work, and the structure is not intended or offered
for Wer (Sec. 70441, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law don not apply to an owner of property who builds or improves thereon,
and whodon such work himself or through his own employees, provided that
U-wJ
such Improy.ments are not intended or offered for ,ale. If, however, the
OTHER (SPECIFY)
building or improvement I. ..to within one year of completion, the owner
builder will have the burden of proving that he did not build or improvefor
P.mof .a I.J. �
PROVIDE I.C. B.O. REPORT NO.
❑ I, a of the property, am exclusively contracting with lit.mad
contractors to construct the project (Sec 7044, Business and Professions
Code: The ContractoisLicense Low does nor apply toanowner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves ther.un, and who contracts for Such projects with e
contractorW licensed pursuant to the Con Vector's License Lew.
❑ 1 em exempt under Sec. ,B.&P.C. for this
'all
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Data
hS
WORKERS' COMPENSATION DECLARATION
A
P
Building V
1 hereby affirm that hove a cerci ficota of consent to sell insure, or a car
caof of Workers Com a.,ion Insurance, or acertified copy thereof (Sac.
®�'
050
3800, Lab. C.).
.Seismic
Policey No. Com pony
c tilted coon is hereby furnished.
Cer ti lied is filed the inspection division.
N/
' "� V
1
Total
copy with city `/
Applicant
/ C
(,&,PERM( AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. 0
rf//NU
COMPENSATION INSURANCE
(Thi, faction need not be completed of the if for one hundred doh
permit
bre 121001 or
I caI he, i of the work for which this permit is
that in the pan,
issued, 1 moll not employ any parson in any manner to of to become subject
h person n
to the Worbri Compensation Law. of California.
�V Y
Date Applicant
NOTICE TO APPLICANT: If, altar making this Certificate o1 Exemption,
you should become subject to the Workers Compensation provision. of the
Labor Cod•, you must forthwith comply with such provisions or this permit
All roofs shall be inspected prior to any roofing material being
.hall be deemed ravoked.
I certify chat I have reed this application and state that the above Inform,.
Installed If a roof is Installed without first obtaining an
hon is correct. 1 agree to comply with all city and county ordinances and
inspection, I agree to remove all ne mat enalsforinspection.
.,ata laws I.I•ting to building construction, and hereby authorize represam
lativn of this city to entre upon the above mentioned property for impaction
'u'p....x�Aly
we)gre• ,eve, intsmnHy and bap s the City of Cupertino
IWAf
f/�`VJ
which
s, costs of and expenses migwhich mem In any way •[true
against liabilities, consequence
.gainer old City th corwquanca 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
SUBIECI': REROOFING POLICY POR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPEC'T'ION PIIASE.
L Prior to penuit Issuance, you must agree to comply will, U.D.C. standards slid manufacturers specs
or reroofing.
2. New roof coverings shall trot be applied without first obtaining all Inspection and written approval
from lire building inspector. A final inspection mrd approval shall be obtained front lire building
inspector when lire reroofrtrg is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4, in order to receive a (ural, you mus[ complete steps 1, 2, and 3.
1,) Preinspec[ior or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. if plywood is installed, a Plywood nail irspecliotr is required.
G. if any roof is applied without first obtainiag all irspeclion, you will be required to remove all new
material down to the sheathing and a building iuspeclor will inspect all slrcall,irg at that lime.
WE UNDERSTAND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY Q
HOMEOWNERS NAME:
ADDRESS: /V1
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RerooUwinword
0
Cittl of Luper irlo
4
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
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 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 sm Ike detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER:
I-IOMEO WNERS SIGNATURE:
DATE: 3- 3/-
0
/-
• winword/smkdet