R-4614 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4614
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ti4
BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
Avel KexS e RESIDENTIAL COMMERCIAL OTHER
OWNER'S r `,, understand
HAZARDOUS FIRE AREA
NAME N61y'�'h��—'""��-�" VES ❑ roof reqiredthat Dla55A
roof assembly wired.
�,,pp (� '_� ` C o NO Initial I.C.B.O.q
ADDRESS IiV l5 `�^r'vy V�yC ry' � r - EXISTING ROOF COVERING
PHONE UD 5 1 NUMBER OF EXISTING COVERINGS
CONTRACTORS
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
L_n n' N �I TYPE OF ROOF COVERING
N C.
CITY a ZIP EXISTING
fix
PHONE BUILT-UP ROOF ❑
LICENSE
r NUMBER U ASPHALT SHINGLES - ❑
LICENS CONTRACTORS DECLARATION
I hereby affirm that I am llcansed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license is in full force and ,
effect. WOOD SHINGLES t v5�3
E]License CI ss Lic.Number ((�
Data comreclor t� I OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED $�/� 2 0
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. P/ VV '1���
(Sec.7031.5,Business and Professions Cade: Any city or county which requires a permit to /
construct,after,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UPjROOF Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions wr UUPE
Of the Contractor's License Law(Chapter (commencing with Section]000)of Division 3 of the r 1 fiNy
h
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section by any applicant for a permit subjects the applicant to
phundred
a civil penally of not more than live hundred dollars(h wage: WOOD SHAKES ❑
I,as owner of the properly,or to employees with wages as their sola compensation,will s-
sio work,and the ontrajg is not inserdediLaw ores not for sale(Sec owner
of Business and Profbuilds
or Coda: The.an who
License Law does not apply toanowner ofproperly who buildsor WOOD SHINGLES ❑
improves thereon.and who tloas such work himself or through his own employees,provided that
such improvements are not intended th affaratl for sale.ill however,the building or improvement
I. bulsold l or
prove for purpose
sthe ownervbuilder 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.70".Business and Professions Code: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 tar such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.far this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: cow
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provitletl for by Section 3700 of the Labor Code,for the performance of the work for which this
, m is issuetl. Q �p3 'per $eISR11C
(T��I have andwill maintain Worker's Compensation Insurance,as required by Section 3]00 of I 4Ul ,2 1/ ]
dtdL&t,or Code,for the performance of the work for which this permit Is Issued.My Worker's
CerrePoll number are. �e _ in A
MTotal
Carrier �; i PoncyNo. �
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN
(This section need not be completed It the permit is for one hundred dollars($100)or lees.)
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shalrbe inspected priortb any roofiri militerial being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become applicant understands and will comply with all non point
subject to the Workers'Compensation provisions or the Labor Code,you must forthwith comply
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 correctI agree
to comply with all city and county ordinances and state laws relating to bcllding construction,and All roo'f//c)p'V�e�n-"ngS to S.C'Or better./��(t
s
hereby n purpoauthorize representatives of this city 10 enter upon the above-meNlonad progeny for In. , •'��I Y
sp fi e)agree tos.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the 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
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without 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 must complete steps 1, 2, and 3.
I,) Preinspection 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 inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY (N
HOMEOWNERS NAME: '
r{'`{a cJ� SNS 4e-
ADDRESS: r�
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerool/winword
�C;ty o
�upertino
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE.
I 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.
• I understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER: `
HOMEOWNERS SIGNATURE:
DATE:
winword/smWet
Printed en"leryrled Psper