R-4032 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4032
- INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 111X/ BUILDING USE
X0153 -Pavel t — RESIDENTIALJ� COMMERCIAL OTHER
OWNER'S C4f4Y3dr10 Vi'l 14J,K
��O /1
6/a CoylPteliM MAP , FIREHAZ
No COVERING /
ROOF
NAME l J
4 g V I AREA CLASS
ADDRESS I�Ag hGL'�29S �co, EXISTING ROOF COVERING
PHONE erg - 5s1 -73(,& NUMBER OF EXISTING COVERINGS
CONTRAC``VL Q,L,�OJQLO�
TO BE REMOVEDI TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESSyEXISTING
ITZIP
PHONE —( 1 \Vjjj" e,io
BUILT-UP ROOF
LICENSE �J� 1 l Oct
ASPHALT SHINGLES
NUMBER G L X
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION _
I hereby affirm that 1 em licensed under provisions of Chapter B(commee
ting with Section 7000) of Division 3 of Me Business and Professions Code, WOOD SHINGLES
And my license is i fullJHfarind affect.
Licens an Lic.Number
Da. — — Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION �J
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
or county which requires a Permit to on eruct, alto, improve.demolisn,or
,.Pair am structure,prior to in issuance, also requires the applicant for such BUILT-UP ROOF
permit to 111.a signed statement that he is licensed pursuant to the provisions
of he Contractors License Law (Chapter g (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant fora permit Subjects the applicant to a civil penalty
ofnot more he,if..hundred dollar.(S6oO).): WOOD SHAKES
❑ 1, es owner of In.property,p in,employee.with wage.e.their..I.
Compensation,7willoaa, Business end Profession.Code: The Contractor's licdo the work, and the structure if not intended or offered WOOD SHINGLES
for .I.(Sac. ense
Law does nor apply t0 an owner of property who builds or improves[hereon,
and Wn0 don such work himself.1 through his Own employeaa,provided that 'T
pch imciem.
prnt. are no, in,.nd.d o [offered for sale. It, however, the OTHER (SPECIFY) TIC. -Din 'L
building or improvement is sold within one year of completion, the owner
bui tle.will nava the burden of Proving that he did not build or improv for
Purpose of sale.)' PROVIDE I.C.B.O. REPORT NO.
❑ 1, e. owner of the heproperty,project
t ( ec. 7 44, convecting with licensed
contractors to construct the project (Bac. 7090, Business and Profetsiom
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves theraun, and who contracts for such projects with e
contractor($)licensed pursuant tothe Contractor's License Law.
❑ 1 em exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owear Date P^
WORKERS'COMPENSATION DECLARATION BUlldin
I hereby affirm that I have a certificate OI consent to self insure,Or a car. '
ti(iceis of Work.,.C.mpen.etion Imur C `ified copy thereof(Sec. SeISrn IC
3800,Lab.�50�.55& i�el u; I ' 4 10 ? of b. �
Policy No. mpanv 1 L Trda M C/ T0181
r'1 PENS liatl copy b hereby turnLMd. _.J
'/
B�Ler ti rise y,ppy filed with n'city inspection di✓pion. !� /9 /�
Applicant /ly=e T
CERTIFILOF EXEMPTION FROM WORKERS' NC
❑ IT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol*
...($100)or Ion.)
I certify that in he performance of ins work for Which this permi[ is
issued, I shall not employ any person in any manner so e.to become subject
so the Worker:Compensation Laws of California.
DateApplicant
NOTICE TO APPLICANT: If, at,., m.king this CarURtera of Evmption,
you should become subject to the Work.,.Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit All roofsahall beinspected prior to any roofing materiAlbein
shall be d.emed revoked.
1certify That 1 have read this application and state that the above informs Installed. If a roof IS Installed Without first obtaining an
tion is correct. I agree to comply with e0 city and county Ordinances and Ina ion,I ag�®rVe 811 ne materials for inspection.
state laws relating to building construction, and hereby author its .,,.an
tetives of this city to enter upon the above mentioned property for inspection eee777
purpose,,
(We)
spree to sew, indemnify and keep harmlm the City of Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in cons.quence of the granting of this permit, SIGNATURE AP LICANT 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
SUB1ECf: REROOFING POLICY FOR TIIL• CITY OF CUPERTINO BUILDING DEPART hIL•NT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied wilhout first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained Iron,, the building
inspector wile,,the reroofr,,g is comple(ed.
3. All types of roof shall be inspected prior to ally roof being installed.
4. In order to receive a final,you Must complete steps 1, 2, and 3.
l,) Preinspection or tear off approval.
2.) In progress inspection approval.
• 3.) Filial inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. if plywood is installed, a plywood nail inspcctio,,is required.
G. 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 little.
WE UNDERSTAND TILE ABOVE POLICY ON REROOFING AND WILL CONIPLY WITH THE
POLICY � p
HOMEOWNERS NAME:
ADDRESS: 1 0 1 `J Pet r'iCl�(-
,
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
•
CITY OF CUPERTINO
BUILDING DEPARTNIENT
Rerooflwinword
i
Tial of CNperii"D
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.
1 understand the above requirement and certify that we now have sm Ike detectors
installed that do comply. —1
ADDRESS: Jot 53
PERMIT NUMBER: R � 40 3�`
XJIOMEOWNERS SIGNATURE: Y
.,D,DArE: I I c1
winword/smkdet