R-4116 ' PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4116
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM T ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - Y BUILDING USE
NWhe4aii^IU2 RESIDENTIAL_LY_ COMMERCIAL OTHER
OWNER'S
HAZARD
OOF
NAME 1'1 E- � lQ. dQY)1lfr IIFIRE OUS C
�AOVVSES ING
ADDRESS S / WVI ' eri1l EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING C VERINGS
CONTRACTOR'S �f,,��1
NAME V es fo/a sate- gao( 'i 74 TO BE REMOVED TO BE RETAINED
,f' pp�������� w�t�tI�� I�'� TYPE F ROOF COVERING
ADDRESS
CITY&ZIP ��Q1� — LJ N.F-(M PA/? /rl 146N �y0Y3 EXISTING
PHONE � 5'/ 20— 615 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I ftenby affirm 7000 I of licensed under Om visions of Chapter 9 on.Coca
rid wtrn Section l000l of Division 3 of me eD.m...and Profession.cod., WOOD SHINGLES
end my Ilunse if in full 1 rte and Nf«c
Lic.Pas f Lice Number
Data Contractor OTHER (SPECIFY)
WNE RBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the lotlowing reason. (S«. 7031.5, Business and Professions Code: Any city
county which requires a permit to construct, .Iter,improv, d.molish,or
rep.
.nv.,t,.ctur.,Prior 10 It issuance.also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he If licensed pursuant to In.provisions
of the Contractor'. License Law (Chapter 8 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda)or that he is exempt mere ASPHALT SHINGLES
from and In. basis for [0e:11.1 111 e.emD\ion. Any vioi.tio. of Section
7031.6 by any applicant for 0 permit subjects the applicant to a civil penalty
ofnot morethat five hundred poll...($500).): WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages a their sole
compensation,will do the work, and the structure if not intended or offered
for sale (Sec. 7044. Business and Profession$Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvement ere not intended or offered for sale. It, however, the OTHER (SPECIFY)
building or improvement i sold within one year of completion, the o
builder will have the burden of proving that he did not build or improve for
purpose.1 sea.). PROVIDE I.C.B.O. REPORT NO.
D I, as owner of the property, a exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Profession,
Codmi
.: The Cor«igs License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves menun, and who contracts for such projects with s
contractor(N licensed pursuant to the Contractor's License Law,
E) 1 am exempt under S«. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
owner Data-
WORKERS'
^—
y WORKERS'COMPENSATION DECLARATION or {2 ®.� IfJklJv Building
I M1ereb affirm that I neva a certificate OI consent to self-insure,o
tificab of Workeri Compensation Insurance.or a certified copy thereof(Sea //2);,o F,o as Seismic
3800-L.b.CJ L ftp /1,-�� lr �--
PolicyNo.NWL91�954�QomDany -S[
aCertified copy is hereby fppppurnp000i1/shte'd }PIC'' /� 1996 Total
C.rtif.d coq 'A�fJje MPTf1';J ROOM Iv,uon.
Applicant f All� i1 '1+ OT
C R IFIL ATE OF COMPENSATION
INS FROM W RKE RS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENS millet INSURANCE
IThie action head not be completed if the permit is for one hundred aob
Ian IS1001 or lanai
I
:This
that in the performance of the work for which this permit Is
issued, I shell not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California.
Deb Applicant
NOTICE TO APPLICANT: 11, alter .eking this Certificate of E..R ion,
you mould become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with Such provisions or this permit All roofsshallbeInspected prlortoanyroofing material being
&hall be deemed revoked.
I certify that 1 have read mif.pphcation end stase Ina\me.bove Informs Installed If a roof is installed without first obtaining an
non is pq,nacJ. I agnea 10 comply with .0 pity and county ordinances and Inspection,I agree to remove all new materials for inspection
state laws relating to building construction, and hereby authorize repre&en' - ('1 �1
teti ver 01 this cloy to enter upon the abovementioned harmless
property for inspection JIU WI Q /1^l �/ I I 9/ /!
Purpose.. 111(II II]' iL11A1YI'y/ L.1/� L/
(We)liabilities,abroe uve, indemnify end keep es which the City of Cupertino
against Cti cons a tee,costs and expanses which may In.nY waY«true
.win&[uid cb in consequence of ma granting m this permit. NATURE 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
SUB1ECf: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you ulust agree to comply with U.B.C. standards and manufacturers spec's
ou reroofing.
2. New roof coverings shall not be applied lvitlwut 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 Illus(complete steps 1, 2,and 3.
1,) Preiuspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
• nJ Operable smoke detectorvcrificalioll
bJ Spark arrestor installation
5. If plywood is installed, n plywood nail inspcctiou is required.
G. Ir ally roof is applied without first obtaining an inspection, you will be required to remove nll new
material down to the shattlting and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TI1E-
POLICY
HOMEOWNERS NAME: Gh ( [a a ha ' J
1
ADDRESS: 19 tq 9S-LI
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CHY OF CUPERTINO
• BUILDING DEPARTMENT
Reroof/winword
- - i
Citvj of cmVerli"O
S,IIOKE DETECTOR CERTII'ICATE OF COMPLIANCE
1 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:
HOMEOWNERS SIGNATURE:
DATE:
I
I
winword/smkdet