R 4648 PERMIT R_ 4 6 4 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ) p✓�
RESIDENTIAL COMMERCIAL OTHER
OWNS ,s HAZARDOUS FIRE AREA
//� YES E3If yes-I understand that a Class A
NAME
roof assembly is required.
NO. Initial I.C.B.O.#
ADDRESS— / /IJ�LF ��Xw EXISTING ROOF COVERING
PHONE , TJ NUMBER OF EXISTING COVERINGS
_ CONTRACTOR'S p
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS t //� TYPE OF ROOF COVERING
CITY&ZIP - _ q. !�C. EXISTING
PHONE / 7 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and -
effect. - ?6 WOOD SHINGLES ❑
License C Llc.Numher
7
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATI PROPOSED
hereby eft ran that m azampt from the Contractor's Lica a Lew for the following reason.
(Sec.7031.5,Business and Professions Cotle: Any cIN or unly 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 a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basic 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 live hundred dollars(§500).):
❑I,as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles.
slons Code:The Contractors License Law tloes 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 ,e y
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B4O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for Such projects
with a contractor(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B It P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION D E < VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, _ 2 4 1995 Building k
as provided for by Section 3700 of the Labor Code,for the performance of the work Mr which this
permit Is Issued. -
❑1 have end III maintain Workers Cc pensallon surence,ea requlred by Section 3700 of � P L7 $elSrlllC
the Labor Co for the pe armance o work to,
which Ihls permit le issuad.yy Worker's G'I I LUU4,v, dhlt Total
Comperma n Insum a rrler antl P y numb re: J
iam
Carrier N41 A e PoncyN *—O PERMIT AUTHORIZATION DATE ._
CERTIFICATE OF E MPTION FROM WORKERS'
COe d If
ION INSURANCE N,O.I] y� �� n
(Thus section nth, not be comple etl II the permit hundred tlollere($100)or lasso ��CTL_-\1
I certify,Thal In th nner so anc f the work for Ich this r It Ie IS,
shell not employ
any person In any neer so ae become sub t m m war 'C sensation Laws or cam All roots shall be inspected prior to any roofing material being
forme. installed. If a roof is installed without first obtaining an
Date l7 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLI T: 11,eller making this CBrilllc I Exemption,you should become icant understands and will comply with all non point
subject to th Workers ompensetlon provisions of the or Cotle,you must forthwith comply p Y p
with such provisions or this permit Shell be deemed re d. SOUr regulations.
I certify that I have read this application antl stele t the above Information le correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and Allr oBrings&Oblass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property lar in.
spection purposes.
(We)agree to save,Indemnexpenses
and keep hay lessway the City of Cupertino Sold Ci y Inagainstcon liabilities
of mento,conte and permit. s which may In any way accrue against sold City In consequence
onhe granting of this Parma. SIGN RE OF APPLICANT AT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE 61 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 '
t?
' CitV ter
tiperthu o
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� I understand the above requirement and certify that we now have smoke detectors
installed that do comply. p
ADDRESS: hJi I Kin Son A ✓e;
PERMIT NUMBER: ` q- 6 q-;?
nn
HOMEOWNERS SIGNATURE: A "� 6�bj A
DATE: r 1 /,Z� /� 9S"
winword/smkdet
Printed on Recycled Paper
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.
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
HOMEOWNERS NAME: C/
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword