R-3575 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Rals 3 3575
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 IF WORK IS NOT STARTED
yETHIN 180 DAMIT YS OF PERMIT ISSUANCE OR
Iso DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS UILDING USE
2 3 114 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
ROOF
NAME A� �/ FIREARDOUS � COVERING
AREA CLASS
ADDRESS Say► cC /� EXISTING ROOF COVERING
PHONE �/ —2 3 v NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S �(�,�
NAME Y 164 �,J TO BE REMOVED TO BE RETAINED
/ TYPE OF ROOF COVERING
CDDR&ZIP X60 --�dy 122-10 EXISTING
PHONE 16W ya �J O /�i3�_ BUILT-UP ROOF
LICENSE / ASPHALT SHINGLES
NUMBER 6P W
LICENSED CONTRACTORS DECLARATION �° A L E
I hereby Affirm that I em liters d under provisions of Chapter 9(commen. 1111 '1
Ting with Section 70111) of Division 7 of the Business and Prof.es od., W OD SHI G II
and my license is Inl0i1 f d effete I ry -� 1 p UI
and me Cie. C- LIc.Number Inns 011 E R�jSPECI
Data Contracto. p]y
OWNER-BUILDER DECLARATION J DATE
I hereby affirm that I am exempt from the Contractor's License Lew for PROSE) -
The following reason. (sec. 7031.6, Business and Professions Code: Any city
Or county which rnuiros • permit to construct,alto, improve, demolish,or
repair any Sir Flute, prior to ill issuance, also requires theappliunxfor such BUILT-UP ROOF
psmit to ills a signed statement that he Is licensed pursuant to the provision
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
from
Division 7 of the Business and gedf exam%tion. or y violation exempt thee' ASPHALT SHINGLES
from end rise befit for the ellarmi exemption. Any atto of section
7031.8 by any applicant for•permit subjects the applicant to a civil penalty
or not mor.that five hu ndr.d dollar,( 500).b WOOD SHAKES
I,of owner of the property, or es my employewith wages as their sole
compen..t ion,will do the work, andthe structure is not intended or offered WOOD SHINGLES
for fele (Sec. 7044, Business and Professions Code: The Contractor f License
Law does not.poly to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements a not intended or offered for sale. If, 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 for
purpos.of".1.3, PROVIDE I.C.B.O. REPORT NO.
1, of owner of the property, am exclusively convecting with licensed
cantractors to construct the project (Sec. 7044, Business and Profession%
ode: The Contractor's License Law does not apply to an owns,of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such projects with e
contractor(.)licensed pursuant to the Contractor's License Lew.
p 1 am exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Own.r Data O�
/'9
WORKERS'COMPENSATION DECLARATION p I � aC Buildin
I hereby affirm that 1 have a certificate of consent to fele-insure,or g car
fifican of Work.,.Compensation Infur e,or a car ti Tied Appy thereof
(Sac. nn Seismic
7800,Le0�9Ss[.Z dem Alt
Policy No. mpeny `]/
❑ Cersi__ copy hereby fury had. / AY 09 1994 Total
meant IRed copy i%filed with me city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERSN C ❑ TAUTHORIZATION DATE
COMPENSATION INSURANCE v
(This section need not be completed if the permit is for one hundred dol rr
lora III or lass.)
I certify that in the performance of the work for which this permit is
issued, I shell not employ any person in any Mannar to as to become subject
to the Workeri Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: 11, attar making this Certificate of Exemption,
you should become subject TO the Workers' Compensation provisions of the
Labor code,you must forthwith comply with Such provisions or this permit All roofs shall be Inspected prior to any roofing material being
Shelf be deemed revoked.
Icertify that I have reed this application and feet.that the move inform.. Installed If a roof Is Installed without first obtaining an
.on
is correct. I agree to comply with all city and county ordinance.and I pection,I a ree to remove all new materials for Inspection.
env laws relating to building construction, and hereby authorise rmrarem
natives of this city to enter upon the above rnamloned property for irupaGion
purposes. Fe
IW-1 spree to tees, indemnify and bap hopeless the City of Cupertinoal
awinst liabilities,judgments,torts and expenses which may in any way-ecru- % �^
against said City in consequence of the granting of this permit. SIGNATU E 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 _
• SUIJJECT: Rlilt00FING POLICY FOR "1'111• CITY OF CUPI RTINO BUILDING DEPARTMENT
Plt101t'1'O ISSUANCE,OI'PElttvil'I' AND INSPECTION PHASE
L Prior to permit issuance, you must agice to comply wilh U.U.C. standards aid utanufaclircrs slices
Oil reroofing.
2. New looteoverings shall riot be applied wilhool first obtaining all inspection and written approval
from Ilre building inspector. A final inspection and approval shall be obinincd from the building
inspector when the reroofing is conorleed.
J. All types of roof shall be inspccicd Prior to any roof being iustnlied.
4. In order In receive a final,y'oll must colnplc(c slcps 1, 2, and J.
I,) Prcinspcclion or tear off approval.
2.) In progress inspcc(ion approval.
3.) Final inspection approval.
a.) Operable sntolcc dcicctor vetifica(ion
• b.) Spark arrestor installation
5, If plywood is ill mallcd, a plywood nail inspcclion is rcquircd.
G. If any roof is applied riWoul first obtaining an inspcclion, you will be requited to remove 111 new
material down to the sheathing and a building inspector will inspect all sheathing at lhal lime.
WIi UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY Wulf 'rllE
POLICY
IIOMf_OWNERS NAME:
GL 4 L
ADDRESS:
2 4 ? 1 �l91 e A4 4,,C,
REROOFING COMPANY NAME:
APPLICANTS SIGNA'I'Ultf: L
CI'T'Y 017 CUPERTTINO
BUILDING DEPARTMENT
Rcroofhvimvord
Citri of CtApeI•tilio
P.O.nog soo
10700 loi n:Avenue. Cupertino,CA 95015-0500
Cup,jinn,CA 95014-7255
lcicphom:; (400) 252-4505
M%: (4011) 2.52-0757
COMMUNI IY Dr:V@lorMENI
SMOIU DC-FE.C1'OR CLRTII_ICA1'L OI' 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 :61,000, a smoke
detector will be installed, mounled on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or arca givilig access to room used for sleeping
purposes. ]f existing smoked 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 SIGNA'I'URG '
DATE-:
winword/snikdel