R-4166 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ra 4166
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL - COMMERCIAL OTHER
Nf R'S
N.
I )e)\)
� C�OLJ HAZARDOUS ROOF
NAME nC4 W FIRE COVERING
�y� AREA CLASS
-AZQKESS 1�r+�''P ck"NL-A -rAlE tA^fE EXISTING ROOF COVERING
PHONE 1,(-00o 153 *3711 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S ✓
NAME WF5 TSHQZ_jL 20Of_7�JC— Com, TOBEREMOVED TOBERETAINED
/ TYPE OF ROOF COVERING
AD
CIITDY 81 RESS ZIP _(818 (.�. f( �1.. SF. ft(oi? 77 (Y EXISTING
CA 9536 '
PHONE
-Lo") 933 'D-554 BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER 65 -2399
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
1 with
offiSection
that 1 of Division
under aPr.vi.hm.ness a Chapter 9(nommen
ing with license
70001 of Division 3 or ms Business and vrofwioo Cpa., WOOD SHINGLES
and my Ilcenu i{i full yo •ep0 affect.
License Cba 3`/rq Lin.Num., 6S 737$
Data Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt nam the Contractor's License Lew for PROPOSED
the following reason.
ss
(Sec. 7031.5, Bu.ineend Professions Cori Any city
or county which requires a permit 10 construct, alto, Improve, Camgli+b,Pr
rabelr any structure, prior to its issuance also require+the implicant for such gUl LT-UP ROOF
permit to fila•{ignad+busman[thea he is licensed Pursuant to the provisions
of the Contractor', License Law (Chapter 9 (commencing with Section 7000)
fromDivision 3 of the Business and Prob.nioo Code)o,that of ti exempt mere ASPHALT SHINGLES
Irgm entl the Anis for :h auegaa a amption. Any violation of Section
7031.0 by any applicant fora permit subjects the applicant to A Civil penalty
of not more that five nonmed dollar.(S5001.): WOOD SHAKES
❑ I, as owner of me property,or my employ...with wage,a mail side
com Pantetlon,will do the work, and the structure is not Intended o offered
for.e4 (Sec. 7044, Business and Prof es.ion+Code. The Contractor's License WOOD SHINGLES
Law doss not apply to an..her of property who builds or improves ova.provided
he, I
La who does such work himself or[morph w own ills or ees,imp ovesi the tont L
{uch improvement, are not intended oroffered for sale. I1, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve efor
Purposeof"a.). PROVIDE I.C.B.O.B.O. REPORT NO. L♦.'>_3
❑ 1, of owner of the property, s .c lmivaly contracting with licensee
contractor+ to construct the project(sec. 7044, Business and Profession+
Code: Th.Contractor. License Law do.,no,apply 1.an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves ther un, and who contracts for such projects with a
contractor(.)licensed pursuant to the Comr.nmr.License Law.
(:j I am exempt under Sac. ,S.&P.C.for this
ow{ho. erste PIRDOATI DATE VALUATION PERMIT FE
WORKERS'COMPENSATION DECLARATION �o o Building
1 herby affirm that I have a certificate of consent to self insure,or a Cera
tifiu'a ql
Workers'Compensation insurance,or•certified copy thereof of
1V $ei$mjC1� _
3800, Lab.C.). 1'L Q O
95
Policy No. Company
8 Certified copy is hereny furnished. QI Y Uf GUYtKr(N0 Total
Certified copy is filed with the City inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' .N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Thi{section need net be completed if the permit is for one hollered sol
I...($10"This or las.)
I Car
iify that in the performance o1 the work for which this permit it
to the l�
issuaa, I .hen not employ any parson in any manner so as to become subject (�■\\
Work.I Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You should become subject to the Workers'Compensation pmvisi on+ 01 the
Labor edea, revoked.moat forthwith comply with .pnM1 Provisions dr this Permit
.hen be deemed
All roofsshall be inspected prlorto any roofing material being
ea
e
I certify that I have read this application and state that the above inform.. installed If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with ell city and county ordinances and jngpeet ,I gree to remove all new materialsfor inspection
.tete law. relating to building construction, and hereby .etnorita r.pra.m
tetivns of this city to anter upon the above mentioned Property for inspection
Pumose.. S. 30. `?-5
'I st liabilities.aer.. to save, Indemnify and keep M1armlw the City of Cupertino
against id iyi corse Cie anis and axpana+which is may in any way accrue
against said City inconsequence of the granting or this permit. SIGNATURE 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
SU
B1EC`r: REROOFING POLICY FOR TIIE CI'IY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
L Prior to permit issuance, you trust agree to comply with U.H.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied witlroul first obtaining all inspection and written approval
from lire building inspector. A final inspection and approval shall be obtained fram the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
d. In order to receive a final,you loud complete steps 1,2,and 3.
1,) Preinspectiou or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Opernble smoke detector verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
G. if any roof is applied without first obtaining nu inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERS'T'AND 171E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY r
HOMEOWNERS NAME: n 6 r/ LJ a' CLe w
CD/
ADDRESS: (OSIS
0, --T 6,A
z— o. f1 /
9S
REROOFING COMPANY NAME: t e
APPLICANTS SIGNATURE:
• CfI'f OF CUPERTINO
BUILDING DEPARTMENT
Rerool winword
1
Cit of Cupertino
s
SMOKE DETECTOR CERTIFICATE 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 requii ed.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADDRESS:
r PERIVUTNUMBER:
HOMEOWNERS SIGNATURE:
DATE:
r
1
1
r
winward/smkdet i 1
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