R-4165 i
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4165
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN,BO DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS BUILDING USE
n
'�l (.T 2} 50 C.A T RESIDENTIAL COMMERCIAL OTHER
OWNER'SROOF
/+ 1
NAME CjAE./J _ Kar L14 FIREARDOUS COVERING
// AREA CLASS
ADDRESS 2a4sFS3 SDt,A- $T l.�P�cfTFL� EXISTING ROOF COVERING
PHONE f06 .• Z(,OT NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -�
NAME Y.Nt tit-cr `t�,yr_ttrb Co TO BE REMOVED TO BE RETAINED
��jj
TYPE OF ROOF COVERING
ADDRESS
�(y� �
CITY&ZIP 1.kk> er-1'C-F,` .hi 5-� "ReA ^Ir f+q' EXISTING
PHONE
5—LO y�g-CLO-11 91f539
BUILT-UP ROOF
LICENSE A GqS ASPHALT SHINGLES
NUMBER --1 'Ztt i WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,1 em licensetlneer plovi+.m..f Chapter 9(cpmmem
mg with Section 7000) of DiYi.ion a of In.Bu.nes.and Profession.Code, WOOD SHINGLES
and my Ilcmse i.in Tull force end effect. ry
Ol�te seCl T-_?or Y S Connxro�°r , v ) r0 F OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I em ...lot from the Contac,.,. License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
01 county which requires a permit 1.c.natluct, eI.f,improve,demolish.or
repair any structure,prior m its issuance also requires the applicant fo,such BUILT-UP ROOF
permit to fila a signed 11°1ament that he is licensed pursuant to Ins Provisions
of the Contractor'+ License Lew (Chapter 9 (commericing with Section 7000)
from
Division 3 of ma Business And alleged
...m tion. or that of is n of S me.. ASPHALT SHINGLES
from and the bit* for ,ha all.Pro esions Cod Any violation of Section
7031.5 by an,applicant for a permitubjects the applicant,o a civil penalty
of not more that five hundred dollars($500).1: WOOD SHAKES
❑ I,as owner of the property, ormy employees with wages as their.01.
compensation,will do the work, and the structure is not intended e$1 offered
lot sale (Sec. 7044, Business and Professions Code: The Convector'.License WOOD SHINGLES
Lew don not apply ,d an own.,of property who build%or improves thereon,
and who does Rich work himself or through his own employees,provided that
such improvements are not intended or offered for sale. It, however, the OTHER (SPECIFY) '1�tiU.Gjl3-
building or improvement is sold within one year of completion, the owner
builder will have ,he burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO. za53
❑ I, of owner of the property, a exclusively contracting with licensee
contr°cton to construct the project (Sac. 7044, Business and Professions
code: The Contracto:sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who esu ills or improve$ ther.un, and who contracts for such projects with a
contractors)licensed pursuant 10 the Contractor's License Lew.
ream em ":.mot send.. sec. ,e.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner D.te pp pp��
WORKERS'COMPENSATION DECLARATION P p {F / Building
I hereby affirm that I have a certificate of consent to self insure,or a car
tificeta of Workers'Compensation Insurance,o ani0atl c y thereol,ISec. Seismic
3800,LabNo MAY 3U 19 S
Policy Certified
SSO`144i Company IZe-1b11.t +" eNJ C�
® Certified copy eareby furnished. Total
Certifi.dco i+dil frit 11b ci pe t' n dJsiO .-
Applicant M + N✓��•�ER O -s yr
CERTIFICATE EXEMPTION ROM WORKR I HORIZATION DATE
COMPENS millet INSURANCE
ec
(This stion nee not be completed if the permit is for one hundred dOL
]MI
Ins IS1007 or that
i ' \ '/ 7�//y�,( 4
I c.I sh tnat in the performance n any
work for as which this permit if - - • `�
to the I anal) not employ any pawn in any manner so as t0 become subject
al
to the Workari Compensation Laws of California.
Deva NT:App1ant
y u TCEshould
TO APPLICANT: 11, atter making this Certificate of Exemption,
pooh,
you moble b you
m. subject i m•comply
Workers'h suchCompprovisions
ns or
a the
.hall code, vop mp.1 forthwith gomply wile .seen provi+ion.or tali.permit All roofs shall be inspected prlorto any roofing material being
' .hell b.dmmad rwokad.
1 certify that l nays read this application and state that the above inlorme. installed I Of is installed without first obtaining an
tion is correct. I agree to comply wim all city and county ordinances and inspect! I egr et remove all new materials for inspection
state laws relating to building construction, and hereby authorize repessen
tative$of this city to anter upon the above mentioned property for impaction T�J
purposes.
IWt liabilities.agree save, in ts,cos s antl loop es which ma City ill Cu accrue
ano
gainstidCyi consequence
costs and expenses which er in any sew accrue
against said City inconsequence of me granting of this Dermic SIGNATURE 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
I
,I
Citij of Cliverti"O
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply will, Section 1210-a of the Uniform Building Code.
Section 1210-a requires when repairs to a single family dwelling exceed 51,000, 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.
I understand the above requirement and certify that we now have stn Ike detectors
installed that do comply.
ADDRESS: 2--O1?Q Sats} >T
PERMIT NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
I
winword/smkdet
• I
SUBJEC'I': REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERIvUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied lvilhoul 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 any roof being installed.
4. In order to receive a final,you "lust complete steps 1, 2, and 3.
I,) Preinspeclio"or tear off approval.
2.) 1" progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
G. lr any roof is applied without first obtaining air inspection, you will be required to reprove all new
material down to the slhcalhing and a building inspector will inspect all sheathing at Wal lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
HOMEOWNERS NAIAE: CfC�► 1F$ ]— Ll�✓
ADDRESS: ?A 3 SOL&+ 5-r CI �a
REROOFING COMPANY NAIME:
APPLICANTS SIGNATURE: ��—
• CITY OF CUPERTINO
BUILDING DEPARTMENT
RerccU%%inword