R-46551�
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OFFICE COPY _ ___
PERMIT
R- 465 5
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IBO DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/Z. YorkSS (re—
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
VES ❑ tt yes — I understand fhat a Class A
NAME „ `
roof assembly fs required.
NO Indlal I.C.B.O. N
EXISTING ROOF C/O' VEERII�NG
NUMBER OF EXISTING COVERINGS („ice,
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ADDRESS— / ( �Ic T Q k /' i e-
PHONE (7
CONTRAC
O
TO BE REMOVED TO BE RETAINED
NAME e
TYPE OF ROOF COVERING
ADDRESS
lt�� J'�
CITY &ZIp S/%' %
EXISTING
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9
PHONE —Zp 7-1 [-� /
BUILT-UP ROOF ❑
CENSE
NUMBER Sd 6
ASPHALT SHINGLES ❑ -
LICENSEDCONTRACTORSDECLARATION
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 Cotle, and my license Is In lull force and
effect' /Z
WOOD SHINGLES
License ClassC-• J� Llc. Num or
Data 1e-30-^95" Contractor
OTHER (SPECIFY) ❑
OW NER-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, altar, improve,demolish, or repair any Structure, prior to Its issuance, also requires the
BUILT-UP ROOF - ❑
applicant for such Peril to Ills a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Coda) 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 more than five hundred dollars (5500).):
WOOD SHAKES ElI,
as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes.
sions Code: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
his ownmployeor provided
Improves thereon, end who does such workhimselffoil or through his own employees, provided that
sucororkhi
does
such Improvementssthereand
not ed for sale. If, ebuilding
have burden that he did
.cam r
Is sold within one year of completion, the owner -builder will the of proving
OTHER (SPECIFY) y
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Cade: The Contractor's License Law 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 contrasor(s) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
1 em exempt under Sec. ,B B P. C. for this reason
Owner Ate
APPLICATION DATE
VALUATION
PERMIT FEE
-
WORKER'S COMPENSATION DECLARATION ,
y�
P
li
Building
I hereby affirm under penalty of perjury one of the following declaration:
1 have will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
❑ and
as provided for by Section 3700 of the Labor Code. for the performance of the work for which this
a
permit is issued.
OC
Se1SfIlIC
-11 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
T p
the Labor Code, for the performance of the work for which this permit is issued. My Worker's
'Campens 'on Ins encs carrie nd P lacy number are:
U 1pxs
O
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K��
LAS"
Total
N W �! �' ^ /
D GJ
x
L;[PE_RJMIy AUTHORizATION
DATE
Carder Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars ($100) er less.)
I certify that In the performance of the work for which this permit Is Isun led, shell not employ
any person In any manner so as to become Subject to the Workers' Compensation Lewe of Cell-
All roofs shall be inspected prior to any roofing material being
fornix.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
CEof become
e c you
must forthwou id
Compensation tion provislonis offrtificate
subject Workers' the Labor Code, th comply
with such provisions or this permit shalpbe deemed revoked.
Source regulations.
I certify that I have react this application and state that the above Information is correct agree
to comply with all dry and count' of this cos and sere lana relating e- bolding a and
All roJ�f COVe iris to be class "C" or better.
the property
hereby authorize representetives of this city to enter upon the above-mentioned property for in.
ap epurposes.
.�
3
(Wa) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
(W
(Tl/I/Lll 40/
16
judgments, casts and expenses which may In any way accrue against said City in consequence
SIGNAT RE 0rAPPLICANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _ ___
lit
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
It,
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
pnl Try
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword
a k c- -T
ei ba rYV7
of,
Cupertino
•
0
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 51,000, 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:
winword/smUct
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