R-4639 APPLICATION FOR CITY OF CUPERTINO
NUsRR- 4639
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RIESIDENTII COMMERCIAL OTHER
Ow R' - HAZARDOUS FIRE AREA
YES ❑ If yeas I assembly
is req that. Class A
NAME 1 \77,UUV// l✓�/ roof assembly is required;
Qn ,,� NO E] Imtlal LC.B.O.N
ADDRESS S � EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE Lt
CONT CTOR'S
TO BE REMOVED TO BE RETAINED
NAM
ADDRESS TYPE OF ROOF COVERING '
CIN 8 ZIP
L3- —•JC BUILT-UP
EX
PHONE UI-J� �LUP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Prolessl�ode,and my license is in full force and
effect' WOOD SHINGLES ❑
License Class Llc.Number
Date Contractor OTHER(SPECIFY) ❑
WNER.SUILDER N PROPOSED
I hereby Ilirm that I an exempt from the Contractor's License Law for the following res n.
(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 Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Coda)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
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
1,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(Sac.7040,Business and Profes-
sions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIF p) ,
not build a or Improve ler purpose of sale.).
❑1,as owner 70th,properly,am axdusissions Coding with licensed contractors to construct
the project(Sec.]044,Business and Professions Code:The andwhocon License Law does not PROVIDE LC.B.O.REPORT NO.
apply to c contractors)
owner )property pwho ursuant
thec contractor's roon,
and who contracts for such projects
with 1 c m exempt ulicensed rSe pureuam to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Set. IS 8 P.C.for 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:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building //y• QW.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is issued. `Vgll 1 �! j� wo
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of IL 1r (v\ o Seismic
the Labor Code,for the performer, of fha wor for which this permit is issued.My Worker's 1
-Comp, Insure a errier d olicy numb r ere: �y Total //q.1-0
Carri Poi yN . t1 W PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C�
(This section need not be completed if the permit is for one hundred tlollars($100)or less.) O� N Grr
I certify that In the performance of the work for which this permit is issued shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All rOOL^shall be inspected prior to any roofing material being
lornla. 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 of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shi deemed revoked, source regulations.
I certify that l have read this application and stale that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building constriffO.n,and All rOO�coveringqto bac ss"C" rbetter. fn
hereby authorize representatives of this city to enter upon the above-mentioned property for in. _
spection purposes. Q 7
(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 AYY DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.—DATE— INSP, DATE
TEAR OFF INSPECTION: BATTENS: FINAL: vl t t —
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
inspectpr 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.
1,) 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 UJ� .
HOMEOWNERS NAME:
ADDRESS: O
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTIvtENT
• Reroof/winword
1
cit, of
`Cupertino
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 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 smoke detectors
installed that do comply. 1 /(�
ADDRESS: 1' ` �3)
PERMIT NUMBER: \ ��
HOMEOWNERS SIGNATURE:
DATE:
winword/smkdct
Prmlod on Recycled P