R-4229 APPLICATION FOR PERMIT R_ 4229
CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITH it IBOOAVSOF PERM IT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADE/DRESS/ 1 SS BUILDING USE
t6c J Y J_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S
7� HAZARDOUS f�, W��g ROOF
NAME d lice FIRE ,yCOVERING
AREA CLASS
ADDRESS Q GS EXIST( ROOF COVERING
PHONE — Bz NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME P ^O,e G/f — TO BE REMOV ED� TO BE RETAINED
m �Z s TYPE OF ROOF COVERING
CI o&ZIP �R h 6 � ✓�5 y7�QG d`Z EXISTING
PHONE 72 _ BUILT-UP ROOF
LICENSE ASPH NGLES
NUMBER Z2Z OODSHAKES
LICENSED CONTRACTORS DECLARATION
I hereby Affirm that 1 em licensed uno.,provisions of Chapter 9(comment
ing with section TOW) of Division 3 of the Business and Profession. Code, ODD SHINGLES
end my license Is In full force and affect.
License Cie. Lia Number
Data Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor. License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which require. a permit t0 cOmtrvct, alter, improve, demolish,or
repair eny structure,prior to its issuance, also requires the epplicent for such BUILT-UP ROOF
P.= to ill.a%igi statement that he is licensed pursuant to the provisions
Of the Contractor. License Lew (Chapter 9 (commencing with Section7000)
of Divi.ion 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from end the anis for the alleged exemption. Any violation On of Section
)031.6 d any applicant for a permit exemption,
the Any ant to a civil penalty
of not mor.that five hundred dollars($500).): WOOD SHAKES
❑ 1, as owner of the property, o,my employees with wages as their sola
compensation,will do the work, and the structum is not intended or offered ZEREP;? N0.
for sale(Sec. 7044, Business and Profession%Coda: The Contractor it License
Lew don not apply to a owner Of property sono build.Or improve.Ih era on,
and who don such work himself or through his own employees,provided that
such improvements are not intended o offered for sale. n, however. the ) � w
building or improvement i sold within one year of completion, the own.r
builder will have the burden of proving that he did not build or improve for
Purpose Of sale.).
❑ 1, e. owner of the property. am exclusively contracting with licensed
con tractorsto construct the project (Sec. 7044, Business and Professions
Coda: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
wn0 build. or improve$ person. and who contracts for such projects with a
contractors)licensed pursuant to the Contractor•License Lew.
res❑n em ..amps ands. sap. ,B.aP.c.for this ppLICAT ON DATE VALUATION PERMIT FEE
owner Data L�
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that 1 neva a certificate of courant to sell inwre.or s tees
tificate of Workers' Compensation Insurance,or a certified copy thereof(Sec JUL 21 199.5 Seismic • �'T
3800,Leb.C.1. —f—
Policy No. Company /s
8 C.rdnad copy is hereby the it 4 ��' Total
Canffiad copy is clad withth me city irnpamlOn division. 1*'CU1'tH- 1
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for One hundred dtoL
lar.1$1001 or hat i /e.�
I certify that in Ma performance of the work for which [hie permit I• L/ `/7l.
issued, 1 shall not employ any person in any manner so as to become subject
t0 the Workers-Compensation Laws of California,n
Date Applicant
NOTICE TO APPLICANT: 11, site, making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing materialbeing
.hell be destined revoked.
1 certify of.t 1 nava reed is aPplicauon end 11.1. at le ththe above Informs Installed If a roof Is Installed without first obtaining an
tion is correct. I e".. 1. cothmply with en city and county ordinances and Inspection,I agree to remove all new materialsforinsp ction
smote awe relating to building construction, and hereby authorize represem
moves of this city to enter upon the above mentioned property for inspection
purposes.
(We) agrse to says, indemnify and keep harmless the City of Cu partino
against liabilities,judgments,costs and expenses which may in any way ecru.
against said City in consequence of the granting of this permit. 4GNRE 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 _
SUBJECI REROOFING POLICY FOR •T11E cri-Y OF CUPERTINO BUILDING DEPARTIMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PIIASE.
1. Prior to permit issuance, you must agree to comply wilt U.B.C. standards and ntanuf clurers spcc's
an reroofing.
2. New roof coverings silo" not be applied tivilhout first obtaining all inspection and written approval
from lire building iuspcclor• A final inspccliou and approval shall be obtained from the building
inspector when lite reroofing is completed.
3. All types of roorsltall be inspected prior to any roorbeing installed.
d. In order to receive a final,you Must complete steps 1,2, and 3.
l,) Preinspccdoir or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
• a.) Operable smoke detector verification
b.) Spark arrestor inslallatiau
5. if plywood is installed, a plywucd nail inspection is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove nil ac.v
material down to the shcalhiug and a building inspector will inspect all sltc.thing at that lime.
WE UNDERSTAND TIM ABOVE POLICY ON RERCOFING AND WILL COMPLY WITH TILE
POLICY /
HOMEOWNERS NAME: ^ e
ADDRESS:
REROOFING COMPANY NrVME:
APPLICANTS SIGNATURE:
CfIY OF CUPERTINO
• BUILDING DEP ARTNIENT
Rcrool7winword
.•,�.._-'" Cite of
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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: Z 2
HOMEOWNERS SIGNATURE: f
DATE: /7f�p7 `� �� /,9 9S
winword/ankdet
Printed on 17eaydl d Paper