R-4506 PERMIT R_ 450
6
APPLICATION FOR CITY OF CUPERTINO NUMBER
:1
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DANS FROM LAST CALLED INSPECTION.
BUILDING�yAD/DR/ESSS
/0'360 60 S 4 ok e S Ac,)e, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�} }7--�� /I) YES O If yes—I understand that a Class A
NAME Ill 1✓f'Ie L!ff assembly Is required.
n NO rooInitial I.C.B.O.If
ADDRESS /o360 54okc S A ✓e-, EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Q
NAME C ORYf ef?S' 011 G /�colic
TO BE REMOVED TO BE RETAINED
ADDRESSp'/ o TYPE OF ROOF COVERING
CITY&ZIP S6 r 11,1A L
EXISTING
PHONE6/09) -7 -3 3 BUILT-UP ROOF ❑
LICENSE
NUMBER &9 ZOI -G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
enact' � WOOD SHINGLES El
License Cless 4�f 3 Lic.Number 6C1 2yl/V
contractor 4`70?0 rQ S�o.oG f�Q�,is� OTHER (SPECIFY) ❑
OWNER-BUILDERDECLARATION 1J PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
' of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Cade)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civll penalty of not more than five hundred dollars($500).):
[D 1, SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Elimproves thereon,and who does such work himself or through his own employees,provided that
such improvements ere not Intentletl or offered for sale.If,however,th building or Improvement
Is eOld within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE Iv1FGR.INSTALLATION SPECS.
❑I am exempt untler Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PER FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: �trr��,,
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, "r � � lA y�/ll0 Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.an UG 17 1995 Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 10
the Labor Code,for aIle performance of the work for which this permit Is laeuetl.My Worker'rss
Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. LI I yr `PERMIT A'TH0 4 DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All r00 S shagrible inspect prior to Tyfooting malenal being
forma. -? installed. If a roof is installed without first obtaining an
Date ?-18-9 S Applicant 1)•�•�-'f—'�c�/ � •LC{�r,/ inspection,I agree to remove all new materials for inspection.
subject t.the Worrkere Compefnsation provisionis of theoLaborr Code,cate Of yolu must forthwllith comply become Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
aP Wepurposes.
( )
(We)agree to sada,Indemnify and keep harmless the City of Cupertino against liabilities,ce
judgments,costs and expenses which may In any way accrue against sem City Inconsequence SIGNATURE OF APPLICANT DATE
of Iha granting of this permit.
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 FOR TI1C• CI-I-V OF CUPERTINO BUILDING DEPARTMENT
PR10R TO ISSUANCE OF PERMIT AND INSPECTION PRASE.
1. Prior to permit issuance, you must agree to caruply with U.B.C. standards and nwnuf cturers spe.s
on reroofing.
2. New roar coverings shall 1101 be applied without first obtaining all inspection and written approval
from lire building inspector. A final inspection and approval shall be abinined from Elie building
inspector when the reraefing is completed.
3. All types of roof shall be inspected prior to ally roof being installed.
d. In order to receive a final,you must complete steps 1, 2, and 3.
I,) Preinspcctioll or tear olf approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detcclor vcrificatiou
b.) Spark arrestor inslallaliall
5. Irplywood is installed, a plywued nail inspection is required.
G. Ir any roar is applied without first obtaining an inspection, you will be required to remove all llc:v
material down to the sheathing and a building inspector will inspect all sheathing at Thal time.
WE UNDERSTAND TILL A130VE POLICY ON REROOFING AND WILL CCI IDLY WITH TILE
POLICY
HOMEOWNERS NAME: �31R D) rine/�l
ADDRESS: io3&o S cl�CS AJe�
REROOFING CONLP,\NYNAVIE: CoRvt22s�D.7e �ay�in�
r � .
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Rcraaf/�rimrord
o" of ciipertino '
SMOKE DETL•CTOR CERTIFICATE OF COMPLIANCE
r
1 understand and com 1 with Section 1210-a of the Uniform Building Code.;
Section 1210-a requires when repairs to a single family dwelling exceed SI,000, a smoke '
detector will be installed, mounted on the ceiling or wall in each sleeping room and at a'
he corridor or area giving access to room used for sleeping,,
• point centrally located int , F, �.,i
purposes. If existing smoke detectors comply, no new detector shall be required. y. j
I understand the above requiremeni and certify that we now have smoke `detectors++4i
installed that do comply.
ADDRESS: / U :? (rG am c.✓
PERIv11T NUMBER: i
HOMEOWNERS SIGNATURE: '`ll
/
DATE: ')
i
winword/smkdet