R-4104L-1
LI
OFFICE COPY
PERMIT Ras 4104
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 NOT STARTED
WITHIN 180 DAYS OF MIT EXPIRES IF P RMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
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HAZARDOUS ROOF
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NAME w .LCA'"
FIRE
FIRE�� COVERING �n
AREA CLASS is
reii 4V 0 Or//�—
EXISTING ROOF COVERING
ADDRESS .
t
NUMBER OF EXISTING COVERINGS
PHONE — 7?Ee4P
/ f
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
�e 1��
TYPE OF ROOF COVERING
NAME AAid{�es /[L+ T
"AQC
SIP,
ADDR& A 7✓a 1✓lal f9s�1�
CITY ZSIS '*`4W
r6M4
EXISTING
�S-o3
BUILT-UP ROOF
PHONE t/ -Z��
LICENSE
ASPHALT SHINGLES
„rO�,rY3
NUMBER
WOOD SHA
LICENSED CONTRACTORS DECLARATION
under provisions of On aunt 9 Icommn
affirm the(1 at Division
with 1 70001 of
cing with license u k, 3 m me eu.in...��01}.��. cod..
and my na.nee ify f
WOOD SHINGLES
_ ark,
ar
LI<Into CI• Lic. Number
Det. _� / Contractor a j�
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION v
I hereby affirm that 1 am exempt from the Contractor'. License Law 1
PROPOSED
the following reason. (Sec. 703 1.6, Business and Pr.1...ion. Cade: An, city
or county which requires a permit to construct. alter, improve, demolish,or
repair any structure, prior to its issuance also requires me applicant for such
BUILT-UP ROOF
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor'. License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code) or that he is exempt mare
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation o1 Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that live hundred dollars ($500).):
DOD SHAKE
O I, as owner of the property, ormy employees with wages as their Sola
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
W000 SHINGLES
Law don not apply to an owner of property who huild%or improves thereon,
and who does such work himself or through his own employees, provided that
such imrovements • not intended or offered for Sale. n, however, me
p
OTHER (SPECIFY)
building or improvem nt sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.).
PROVIDE I.C.B.O. REPORT NO.
D I, of owner of the property, am exclusively contracting with licensed
tun to c nstruct the project (Sec. 7044, Business and Professions
rontrec
ode: The Contractor'sLicense Law does not apply toanowner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
who build% or improves thersun, and who contracts for such projects with a
contractor(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt ono., Sec. ,B.&P.C. for this
I ... on
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Oat.
PAID
WORKERS' COMPENSATION DECLARATION
Building
I hereby affirm that have a certificate of consent to self -insure, or a can -
tificete of Workers Compensation Insurance or�,(certified copy thereof (Sec.
SeISmICSearle
3800, Lab. C.I. fid / e—
U� y 221995
Policy No. Company
C.rt ifi.d copy is filed w th tiered. /�
Certified copy M1 filed with the city infwcHon division y/�
�V
V95
�f/f0�
Total
A�D6
AJC
Ur f r
/
am11,
CERTIFICATE OF EXEMPTIONFROM WORKERS' N.C. 0
"PERMIT AUTHORIZATION DATE
COMPENSATION N S URANCE
(This Saction not be completed if ma permit is m1 one hundred do' -i
los ($100)or.I
(Q
i m
1 certify et ma performance of the work too sunto co permit if
that
issued, 1 shall not employ any person in my manner so as to become subject
to the Workers' Computation Laws of California.
Do,.- ApplicAn
NOTICE APPLICANT: atter making this of ion,
Compensation i... of
you should b«oma Subject to ma Workari' Companution provifionf of the
should . pi
Labor Code, you must forthwith comply with such provisions or this permit
All roofs shall be inspected prior to any roofing materialbeing
an x11 be doomed nvgked.
Installed. If a roof Is Installed without first obtaining an
I certify that I have read this application and state that the above informs
tion I. ears«t. l agree to comply with .0 it, and ceuMY ordinances and
Inspection, I agree to remove all new materials for lnsp Of,
state laws rolainp to building construction, and hereby authorise npresem
•'/�
tatives of this city to anter upon the above mentioned property for inspection
pur(INT. sive, indemnity and keep harmless me City of Cupertino
(INTabroo
j
costs
s, i lodgments, Celt. and gra expenses Which may In any waY «Clue
.g.inet laid City
agamn said city in consequence of m• granting of this permit.
SIGNATURE OfrAPPLICANT 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
6
SUBJECI': REROOFING POLICY FOR '1'IIE 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
Oil reroofing.
2. New roof coverings strait not be applied without first obtaining all inspection and written approval
from lite building inspector. A final inspection and approval shall be obtained from lire building
in Winn lire reroofing is completed.
3. All types or roof shall be inspected prior to any roof being installed.
d. 111 order to receive a final, you must courplele steps 1, 2, and 3.
1,) Preinspectioil or tear off approval.
2.) lu progress iuspcclion approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
s. If plywood is installed, n plywood nail inspection is required.
6. if any roof is applied without first obtaining an inspection, you will be required to remove all ucry
material down to lite sheathing and a building inspector Will inspect all sheathing at drat lime.
WE UNDERSTAND '1'11E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TILE
POLICY
IIOIvIEOWNERS NAIAE:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CFIY OF CUPERTINO
BUILDING DEPARTMENT
Rerool7 inword
i
citsl of cuperd"O
SMOKE DETECTOR CERTIFICATE OF CONIPLIANCE
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 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.
1 understand the above requirement and certify that we now have stn Ike detectors
installed that do comply.
ADDRESS:
PERNUT NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
winword/smkdet
iDz� �Znnut�aI� Dt-
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