R-4034 (2) PERMIT R_ 4 0 3 4
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT _ INSPECTION DIVISION PERMIT EXPIRATION
a {408) 252-4505 EXT. 228 OT STARTED
WITH'N 180 DAYS OT EXPIRES IF F PERORK TfISUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I��.p BUILDING USE
Lo2�l ',�14� tS " RESIDENTIAL COMMERCIAL OTHER
OWNER'S Glx/. 2.r -{,•rri V Q_
HAZARDOUS WO ROOF
NAME _C/o tO11 P✓'Qn-,^, �T�—n--C-- - AREA "' ••' CLASS COVERING
I'Sl} ,T Ldp
ADDRESS�0S Qa�S_//P 0. Y5Q032�ca wT EXISTING ROOF COVERING
PHONE � ) �SkP — L p NUMBER OF EXISTING COVERINGS /
CONTRACT S
+ TO BE REMOVED TO BE RETAINED^�
NAME I I TYPE OF ROOF COVERING
CDD&Zip �Of^ EXISTING
�• v r _/ T3
PHONE BUILT-UP ROOF '
LICEN '� („ I e q f 1 9101 �I ASPHALT SHINGLES
NUMBER [/'e WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I h.raby affirm that I em licensed under prwymi n+ol Chapter 9(co11.1
cine with section Tp00) of Division 3 of the Business and Proles ns Coda. WOOD SHINGLES
anLiced nse C my Ilcana h i(311 d.lf.ct 710 t D
•.` VVV� Li....,bar
Data Cantract., OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I thereby affirm that I am..amp[ foto the Contractor's License Lew for PROPOSED
the following resfon. (sec. )031.6. Business and Professions Coda: Any city
or county which requires a permit to construct,alter, improve, demolish,or
/epeir env It dura,prior to its issuance, .110 requires the applicant for such BUILT-UP ROOF
Form it to Elle a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with section)000)
of Division 3 of the Business all Professions tion. or that h•tionof
Section ASPHALT SHINGLES
from and the basis for the alleged exemption. Any the I.exempt
section
)031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mart that five hundred dollars($500).1: WOOD SHAKES
0 I'as of in.property,o my employs.with W.,,a+tnair+Ole
comp....tion,will do the work,and the structure is not intended or offered
for sole (Sec. 7044. Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply to an owner of property who builds or improve+thereon, r
and who don such work himself Or through his own employees,provided that rt �,i{'
such improvement. . not intended o queues far eel.. n, however, m° OTHER (SPECIFY) fV ` ; le_b441 1
building or improvement i• sold within or
year of completion, the owner
builder will have me burden of proving that he tlld not build or improve for
purpose 1 of gown PROVIDE I.C.B.O. REPORT NO.
I, s+ owner of the property, t ( exclusivelyec. 4, contracting a with Professions
Code:
P.The
icensed
to construct the project (Sac. t app Breisans end Pr property
cue.: Ths or improves License and doeswho cot.acts loan owner of pro ith a PROVIDE MFGR. INSTALLATION SPECS.
who ac ilm a eased pursuant
su thereon,t and who contracts for such projects with e
rontract am licensed purer ant[o the Contractor's License Law.
a.pn am exempt under Sec. ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dab p
I hereby affirrm that I have a c COMPENSATION
of conseRAT010N insure,or a car iP I Building
tificate of Workers'Compensation Inw a reified copy thereof(sec Islamic I tLb
3BDD.L.b. 1 0 ° `,�,lo`(�Z- APR 24 199 0,Z4 .
Policy No otopathy 1 H (+-M
ertibed copy i.henbY lurnithee. )y Total
.C."ifi. .Py i• ilea macity' non division. C(11 UL I,
Applicant I
CER IFICAT EMPTION FROM WORKERS' N C PEOMI 5 UTHORIZATION DATE
CO PENSATION I N S URANCE
(This section need not be completed if the Permit is for one hundred dol
Ian($100)or Ina.)
I pnily met in the performance of the work for which this permit is
issued, 1 Snell not employ any person in any manner to as to become subject
to the Workeri Compensation Laws of California.
tab Applicant
NOTICE TO APPLICANT: If, afbr making this Certificate of Exemption,
YOU should become subject to the Workers'Componbiian play Ivan.of me
Labor Code. you must forthwith comply with such Provisions or this permit All roofs shell be Inspected prlOrtOany roofing materialbeing
shall be clamed r..k.d
Icertify the, 1 have read this application and state that the Way*informs Installed If a roof is installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and insp on,I agree to remove all new terialsforinspection.
.,at. laws relating to building construction, and herebyatho rite r.p,...n
tatives of this city to enter upon the above mentioned Property for inspection
purpose
(Vi agree to save, indemnify and keep harmless the City of Cupertino
again., liabilities,judgment.,..at,and aspen +which me,In any Way accuse•
•galn.t said City in consequence of the granting of this permit. SIGNATURE OF PLICANT 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 _
SUBJECT: REROOFING POLICY FOR TILE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIORTO ISSUANCE OF PERNBT AND INSPECTION P11ASE.
1. Prior to perwil issuance, you wast agree to cou,ply will, U.B.C. standards and manufacturers spec's
or 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 [lie reroofing is completed.
3. All types of roof shall be inspected prior to ally roof being installed.
4. Ill order to receive a rural, you rust complete steps 1, 2, and 3.
I,) Preinspecliou or leaf off approval.
2.) Ir progress inspcctiou approval.
• 3.) Final inspection approval.
a.) Operable smoke detector velificalioll
b.) Spark arrestor installation
5. If plywood is installed, a plywood rail inspection is required.
G. If any roof is applied wilhoul first obtaining an inspection, you will be required to remove all ucw
material down to lite sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TRE
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerooftwinword
1
Cittl of CUpef•ti"O
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.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply. {�
ADDR-ESS: ��2 I r �r Gtf
PERMIT NUMBER: 19
IJ
HOMEOWNERS SIGNATURE:
DATE:
I
winword/smkdet