R-4099 PERMIT
APPLICATION FOR CITY OF CUPERTINO INUMBERRoo 4099
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM TISSUANCE OR
I80 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS t/ p // BUILDING USE
3 � ��_ I 11 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
- �/fit AREA HAZARDOUS CLAS
OOF
NAME COVERING
ADDRESS 'w v: cak-g-
V Cz— EXISTING ROOF C
OVERING
PHONE /L10gj2—0 NUMBER OF EXISTING COVERINGS
CONTRACICIFIS
fjA,`� /1 t // / /� T?—
ADDRESS
"7� TO BE REMOVED TO BE RETAINED
NAMEf'—' /�j /WlY—A1/1h�(.� / TYPE OF ROOF COVERING
CDY&ZIP / -/rM 1��1N eo EXISTING
PHONE e77y'—I iR BUILT-UP ROOF
LICENSE '7 ASPHALT SHINGLES
NUMBER C b Z WOOD SHAKES /1
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am license under provisions of Chapter 9(commonWOAD SHINGLES
cing with Section 7000) of Division 3 F1 the Business and Profesflons Code,
and my license I.In II end affect. D1
License C n Lic.Number L
Data contra ter OTHER (SPECIFY)
OWNER-BUILDER DECLAR ON
I herebyefilrm that 1 am...rept from the Contractor's License Lew for PROPOSED
the following recon. (Sec. 7031.5, Business and Profession.Coda: Any city
or county which requires a permit to construct,alter, improve. Perri
repair any structure, prior to its issuance also r.ouires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's Business
Lew (Chapters Code)o that wiis Sact pt 70001 /
from
Division 3 or he.folies.ane Proalleged
exem tion. or that he is n .1 S ctio ASPHALT SHINGLES 7r�
from ae the basis for ma auermi exemption. Any violation or Section
7031.5 by eny applicant fore permit subjects tM applicant to•civil penalty
of n0[more that rive Hundred°aIle.(9soo)m WOOD SHAKES
❑ I, ti owner of ma property, or he employees with wends as r air sole
compensation,will do fns work, Pr the structure if not intends or License WOOD SHINGLES
for do(Sec. apply toein.o *nonen Professions Code: The or improves
License
Lew does not such toe owner or property who n em to impr Fret meson,
and era does such work not int or ed o or
his own employees, however,
owl vetl mer
such ng or improv are not intended or °Hared dor sale. If, nothe owner the OTHER (SPECIFY)
bili der or improvement es sola whnln one year Lf or build pre, [lie
Durpos will have ma burden of proving that he did not build or improve far
p°'pO4eO'•owlPROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner construct
ma property, t exclusively merely Businss contractingwith licensed `
contra<The to tractrum ma protect (Sec. t app Business end Pr prop ore
Wada: TthsConprove% here, Law does no[.actstoenowner oftswithty PROVIDE MFGR. INSTALLATION SPECS.
who bWld. o reprove.pursuant
t, and who actore[LL fore La projects with e
contra<[am licensed purer enc to me Contractor's License Lew.
..on I ore exempt under sac. ,B.FP.c.m.this APPLICATION DATE VALUATION PERM'
Owner Data
WORKERS'COMPENSATION DECLARATION -` it Building
I hereby affirm that I have a certificate of consent to self insure,or acar
Wi<ate of Workers Compensation Insurance,or a cert Hied copy thereof(Sec. JUN ^� Seismic
3800,Lab.CA. V FYI
Policy No. Company
8 C.rffied cap,is hereby furnished. It 995 A Total
Certified copy is tiled with the city inspection division. I Y b��
Applicant car,
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PE •1 AUTHORIIZZZATSIIOOWNN DATE
COMPENSATION INSURANCE
(Thee faction head not be completed it the permit is for one nundrad dol,
Ian 151001 that
1 certify mat m the performance person
of the work for which this permit ^ /e
house, 1 mall not employ any Lenon In any manner so n to become sublact
to tna Workers Compensation Laws of California.
Rete NTplicant
NOTICE should
APPLICANT: o after Workers'
this Compensation
case of Eons ofioh,
you .nosed become subject fort i ms Work tri Csuch pr visa nso r his of ms
shot, Wbea, you must ro.[nwim comply with .ren provisions or this p.rreH All roofs shall be Inspected prlortoany rooting materia'being
.hell be dsems neck..
I certify that I have read this application and state that the above inform.. Installed. If a roof is Installed without first obtaining an
tion i. correct. I agree to comply with ab city and county ordinances andInspectio I agree to remove all new materialsfor inspection.
erns
ste lewd r.I.frrg to building construction, vre
, end thereby authore preeam
nbves of this city to mfr upon the above mentioned Property for inspection
purposes. /
(We) apse to care, indemnify and keep h.misses the City o1 Cupa ino IIILLL
against said
i id liabilities.i judgments,costs and granting
f this mem in any waV a<clue
.wine[sale City in consequence of the nraneng ar[me permit. SIGNATURE OF APPLICANT J E
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:-
INSP.
N-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
1 •�
SUBJECI': REROOFING POLICY FOR TIjE CITY OF CUPERTINO BUILDING DEPARTiv1ENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.H.C. standards and manufacturers spec's
om reroofing.
2. Neil, roof coverings shall not be applied without first obtaining all inspection and written approval
from the building imspeclor. A final inspection and approval shall be obtained from the building
inspector when Ile reroofing is conrplcled.
3. All types of roof slmll be inspected prior to any roof being installed.
4. Ill order to receive a final, you must complete steps 1, 2, and 3.
I,) Preinspection or tear off approval.
2.) Ill progress iuspcclion approval.
3.) Final inspection approval.
r
a.) Operable smoke detector verification
b,) Spark arrestor installation
5. If plywood is iustalled,n plywood nail inspection is required.
G. If any roof is applied without first obtaining it, iuspcclion, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND '171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME: I
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CI'IY OF CUPERTINO
BUILDING DEPARTMEIIT
Reroof/winword
Citil of cupertim
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
1 understand and comply with Section 1210-a of the Uniform Building Code. I
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 useJ 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 sinoIke detectors
installed that do comply.
ADDRESS: /093 In, i
PERIv1IT NU1vWER:
HOMEOWNERS SIGNATURE: hla 1A
DATE:
winword/smkdet
• I