R-4638 APPLICATION FOR CITY OF CUPERTINo
NUMB R RPERMIT - 4 6 3 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (/� \x
O3 Z ��J �� RESIDENTIAL ` COMMERCIAL OTHER
OWNE A n+ HAZARDOUS FIRE AREA
/� .^ S C3If yes-I understand that a Class A
NAME W�v \ V v✓ `�-A- roof assembly is required.
NO ❑ Initial I.C.B.O.H
ADDRESS— n EXISTING ROOF COVERING
PHONE I NUMBER OF EXISTING COVERINGS I
CONT�OR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESSy - TYPE OF ROOF COVERING
CITY aZIP EXISTING
PHONE \ BUILT-UP ROOF ❑
NUMBER
ICENSEam
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. I�.I lx^�y�( � WOOD SHINGLES ❑
License Class Luc.Number 1 ` �- r
Data Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 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 forsuch permit to file a signed statement that he is licensed pursuant to the provislons
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)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 mora than five hundred dollars($500).1: WOOD SHAKES E]I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structural¬ intended or offered for Sala(Sec.7044,Business and False.
sions Code:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who tloes 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 yeaudl,completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY I I
not build or Improve for purpose of sale.). —
O I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE LC.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 MFGR.INSTALLATION SPECS.'
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: U
❑1 have and will maintain a Certificate of Consent toself-insure
Performa for Worker's Compensation, Building
as provitletl for by Section 3700 of the Labor Code,for the performance of the work for which this '//13, �O �j
permit is issued. + Seismic TSf 0
I have and will maintain Worker's Compens tion Insurance,as required by Section 3700 of
the Lobar Code,for the performance of the wor for which this ermlt is Issued.My Worker's Total �y
Com ns it u tic Gerrie Policy num r are: �y I '
CIS
Policy 0. Gl PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars Sit 00)or less.)
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 Can- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subjecttoottn WorrkesCcompensationprovisionsattheCertificate
LaborrCode.yoiumustforthwishould
thbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this apptication and state that the above Information Is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All;oekcovering
t eclass-C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- I
spection purposes. v C y1 - '
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilitlas, 4` I V
judgments,costs and expenses which may In any way accrue against said City in consequence SIG ATURE OF APPLICANT DATE
• of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:NUVl J
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: JI' ;. FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION r T
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 plywomd is installed, a plywood nail inspection is required.
6. If a{*,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
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE: 171
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/winword
`City 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 $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. c _
ADDRESS: ��j
PERMIT NUMBER: ( (v�
HOMEOWNERS SIGNATURE:
DATE:
winword/smkdct
Prinfe�