R-4110 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4110
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 OT STARTED
WITHIN 180 DAYS OFRM TT EXPIRES IF WORK IS ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
�` !` - RESIDENTIAL COMMERCIAL OTHER
OWNER'S y
2�y� HAZARDOUS ROOF
NAME FIRE
COVERING
AREA CLASS
ADDRESS �/910 7 3 /l /C EXISTING ROOF COVERING
PHONE �(„/ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �S �� TO BE REMOVED TO BE RETAINED
/..��/ TYPE OF ROOF COVERING
ADDRESSITb (*z9- Z ,��,� �/jam 1/ 4!!f� EXISTING
PHONE / D� BUILT-UP ROOF
LICENSE ��7 .� ASPHALT SHINGLES /
NUMBER WOOD SHAKES 1�--
L I CENSED CONTRACTORS DECLARATION
1 hereby atlirm that I am licensed under provisions of Chapter 9(common
cin. with Section 90001 of Division 3 of the Business and Professions Cod., WOOD SHINGLES
and my license is in full force and affect.
Lu.me Claw Lic.Number
D.t. Contrx... OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: An,city
or ounty which requires a permit to construct,alter, improve, demalish,or
r pair any structure,prior m ill issuance also requires the applicant for such BU LT-UP ROOF
permit to Ile a signed statement that he is licensed pursuant to the provisions
of the Contractors License Lew (Chapter 9 (commencing with S.Cli.n7000)
of Division 3 of the Business and Professions Code)or that he is exempt there. ASPHALT SHINGLES '
from and the basis for the alleged exemption. Any violation of Section
9031.6 by any applicant for.permitsthe applicant W e civil penalty
of not more that live hundred dollars(9600).b WOOD SHAKE
0 I,as owner of the property.or my employees with wages es[hair sole
compensation,will do the work,and the structure is not intended or offered WOOD SH(NGL 28 1995
for sale (Sec. 9044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds or improves thereon. Cq
and Wino does such work himself or through his own employees,provided that V f (1}
such Improvements are not intended oroffered for sale. If, however, the OTHER (SPECIFY)LUrtiflp
building or improvement is sold within one year of c mpletion, me owner VL
buuder will have the burden of proving that he did not build or improve for
Purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
O I, w owner of the property, a exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE fill INSTALLATION SPECS.
Who builds or improves there. ,and who contracts for such projects with e
contractor(.)licensed pursuant to the Contractor's License Law.
raapn 1 am ex•mat under sec. ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dal.
WORKERSCOMPENSATION DECLARATION Building
hereby Workers'
that ensuhave i certificate , consent to Copy elf sen, o acec.
3fscan ab Wprxe.i Compemetion Insurance,or a coastietl copy thereof(Sac. O x (') Seismic
3800,Lab.C.). r'Z 7 0e d V
Po11cY No. Company
8 Certified copy is hereby furnished. D Total
carbR.d copy is filed with In.City imp•<bon division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTH ATIO DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit if for one hundred dol
lar.($1001 or Int.)
I certify that in me p.rfo,ni of the work for which his permit is
issued, I shall not employ any person in any manner so as t0 become subject
tothe Workers Compensation Laws of California.
D.te Applicant
NOTICE TO APPLICANT: If, after m.king this Certificate of Exemption,
you should become subject to the Workers Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit II roofssh I be Inspected prior to any roofing materiel being
shell be deemed revoked.
I certify that 1 nava road this application and shelf,that the above informs (iristalled. I a roof Is In ailed without first obtaining an
fit, is Correct. I agree to Comply With aB pity end county ordinance.end nspect! I agreeto r all n materialsfor inspection
ware laws relating to building construction, and hereby authorize represent
,rives of this city to enter upon the above mentioned property for inspection
Purposes'
(We) agree to save, indemnify and keep harmless the City of Cupertino
paint liabilities,judgments,costs and expenses which may In any wry accrue
against•old City in consequence of me granting of this Permit. $IGNAT F A LICANT ATE
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 _
SUBIECf: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
L Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
ou reroofing.
2. New roof coverings shall not be applied wilhout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained front the building
inspector when Ilre reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
A. In order to receive a final,you nmst complete steps 1, 2, and 3.
I,) Preiuspection or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke delectof verification /OSS w
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove all new
nmtcrial down to Ilse 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:
ADDRESS:
REROOFING COMPANY NAME: G�
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Remof/wimrord
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citil of cure -ti"O
t)
S�IIOKL^ DETECTOR CERTIFICATE OP 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 iu the corridor or area giving access to robin used for sleeping 1
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:
PERIVUT NUMBER:
AL1
HOMEOWNERS SIGNATURE:
DATE:
I
• winword/smkdet
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