R-4582 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4582
INSPECTION DIVISION PERMIT EXPIRATION
REBORE PERMIT — (aoe)777-3228 PERMIT R
EXPIRES IF WORK IS NOT STARTED
WITHIN 1 X DAYS OF PERMIT ISSUANCE OR
ED
�• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS 9� �//��� rrrJJ�--''VJ P " `L)� C, ' RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Iry I In C' ��1 /yyy J✓I YES ❑ If yes s mbly is eq that a Class A
NAME r rL�I. f LaD N / r i I 11 1 �� NO I roof assembly Is requiredIni
I.C.B.O.N
ADDRESS— )S
U S7 `04-4 C) C� EXISTING ROOF COVERING
PHONE `S > 04-4 U NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
4ll z oo-IP (50a CU TO BE REMOVED_ TO BE RETAINED
��
ADDRESS ?�O ,./O y��Vv� S-r- S J �s( Z TYPE OF ROOF COVERING
CITY&ZIP C"
EXISTING
PHONE �7�lYJ Z`-�3 -9 5 BUILT-UP ROOF El
LICENSE
NUMBER C7 S O 6 Y Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
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 Code,and my license Is In lull force and
affect.
63 --) WOOD SHINGLES ❑
License Class Lic.Number
Date �1 Contractor jolGuy��L OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(See.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
applicant for such permit to file 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 Code)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 then live hundred dollars($500).):
1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code: The Contractor's License Lew does 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.II,however,the building or improvement
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,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cada:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. a&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: P A Il D
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldl Ilg
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
°er'a's and SEP 12 �. Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Workers �� 0 Total
Compensation ITnsurancee carrier and Policy number are: CI !I VVV JJJ
Carrier r Al
r'J t"1 Policy No. �r PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
certify them the performance of the work for which this permit is Issued, shell not employ All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become sublett t the rkers'Compeneali np Laws of Call.
JLC installed. If a roof is installed without first obtaining an
Date 9 Applleent r inspection,I agree to remove all new materials for inspection.
NOTIc TO PLICANT: If,alter making 's Stances of Exemption,you should become Applicant understands and will comply with all non point
sublett to the W rkers'Compensation provi o of the Labor Code,you must forthwith comply PP P Y
with such provisions or this permit shall be metl revoked. Source regulations.
I certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ordinances and State laws relating to building construction,and All roof covMntoe class;@5 class; or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities. ./
judgments,costs and expenses which may in any way accrue against said City In consequence SIG RE OF APPLICANT AT
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
i1
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 TIIE
POLICY i,,^
HON EOWNERS NAME: 111Ln S /� '�h
ADDRESS: 90 S
REROOFING COMPANY NAME: 0 )c G J��L C6
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTIv1ENT
Reroof/winword
• 1
' Cicv of
Cupertino
r
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 in stalled, 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: 965 Ne`^J AIAU Pl^, C�
PERMIT NUMBER: Z
HOMEOWNERS SIGNATURE: tc _ �1 . •L'// •tGrt�
DATE:
winword/smkdet
Printed on Recycled Paper