R-4093 (2) tJ
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 4093
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
RMIT XPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITH I N 180 DAYS OF PERMISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
401 BUILDING ADDRESS BUILDING USE
_ RESIDENTIAL COMMERCIAL OTHER
OWHAZ
ROOF
N E _ '� ^'11-i �yf VIyOs.A ..j FIRE COVERING COVVERING
l ' AREA CLASS
AD S11 01100 Qof
,u.,t:!:\ \ EXISTING ROOF COVERING
PHONE \ I— S ' / Y� f. ��.� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
++ O BE REMOVED TO BE RETAINED
NAME �-- -. nS' hrtti (� �._� r `�3�1.� TYPE OF ROOF COVERING
ADDRESS fie, a
CITY&ZI(+'�t�I 3lcAA��� n- ��NdY�t EXISTING
PHONE f�Imo' BU
LICENSE �/l.t tom.+ 2 AS PHA LT SHINGLES
NUMBER 7
O AKES
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed .der....loons cel Chapter B(common.
ince with S«tion 7000) of Division a of tn.Buenas.and Prof...ionf Code. WOOD SHINGLES
and my license if In full force and effect.
ua.ns.Cls.. Lic.Number
Dan Connxtor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hoobv .ffirm mat Iam exempt from the Contractor's License Law for PROPOSED
the following reason. (Sc!. 7031.5, Business and Professions Coda: Any city
olCounty which requires a permit t0 Construct, alter, improve, demoli.h,Or
pelr any airumure,prior to its Issuance, also requires the applicant for such BUIL T-
permlt to ills a signed statement that he Is licensed Pursuant to the provisions
of the Contractor; License Law (Chapter g (commencing with Section 7000)
of Division 3 of the Business end Professions Codd or mat he I.aeempt moa ASPHALT SHINGLES
from end the basis for the alleged exemption. Any violation of Section
)031.5 by any app)aunt for a Permit subjects the applicant to a civil penalty
of not more mat five hundred dollars($508).1: W KES
❑ 1,a+owner of the property, or my employee.will,wages as tnair sola
compensation, will do the work,and the structure is not intended o offered
for sale (Sec. 7044, Business and ProfnsionsCode: The Contractor's License WOOD SHINGLES
Lew does
not apply to an owner of Property who builds or improves thereon.
and who dam won work himself or through his own employees,PrOvitled Chet
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
-
bulld.r will bava me burden of proving that he did not build or improve for
purpose
pleats.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, em exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Professions
Coda: The Contracmr'fLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for suchlprojects with a
contractors)licensed pursuant to the Contractors License Law.
❑ 1 .m exempt antl.. sap. ,B.mP.c.for this mon PPLICADON DATE VALUATION PERM( FEE
Owner Data r ^ of
WORKERS'COMPENSATION DECLARATION V Building
1 hereby affirm that I have a Certificate of consent to self insure,o !l
[ificate of Worker;Compensation Insurance,or a certified copy thereof(Sac. �� Seismic
38JvAI 00.Lab.C.1. /
Policy No. Company 1
9 Certified copy i+hereby mrnished. Uh w Total
Certified copy i+filed with the City insPeceon division.
Applicant LUf'-
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.❑ PERMIT-) LITHORIZATION DATE
COMPENSATION I N S URANCE
(This section need not be Completed if the permit is for one hundred dol or
Ian($100)or Ism.)
I certify that in the performance of The work for which this permit is six
ifmad, I shall not employ any person In any m sir fes as to became subject
to the Work. Compensation Laws of Californian
Oen Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption,
you should become subject to the Worker;Compensation provision+ 01 the
Labor Code, you must forthwith comply with Such provisions or this permit All roofs shall b oan 9 ected riortroofing terialbein
mall be deemed revoked. P p Y g mag
1 Certify mat I have.snit this application and state that the above informs Installed If roof Is Installed without first obtaining an
tion is correct. 1 agree to comply with all pity and county ordinances and Inspection gre toremo materials for inspection.
11.1. laws ral.ting to building construction, and hereby authorize repression
tatoft Of this city to anter upon the above-mentioned property 10r Inspection
PwpOm. //�
(We) spree to siva, indemnify end keep harmless he City a1 Cupertino
apeinat Iiebilitix,judgments,Costs and expenses which may in an,wry accrue
.wins[said City in consequence of the granting of this psrmif. 1 U APPLIC NT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP, DATE INSP, DAT�ZL 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
SUBIECI': REROOFING POLICY POR TILE CI-17 OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PL-RNUT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply will% U.B.C. standards and manuraclurers spec's
ou 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 front the building
inspector when lire reroofing is completed.
3. All types of roof shall be inspected prior to ally roof being installed.
4. In order to receive a final, you most complete steps 1, 2, and 3.
11) Preinspectiom or tear off approval.
2.) ht progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installation
5. Irplywood is installed,a plywood mail inspection 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 shcalhing al that lime.
WE UNDERSTAND T11E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TIIE
POLICY
IIOMEOWNERS NAME:
ADDRESS: t7 O 1 Ilyl� r 1 i i�
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
it
Reroof/winword
I
Citil of CNperti"O
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
1 understand and comply with Section 1210-a of the Uniform Building Code. I
Section 1210-a requires when repairs to a single family dwelling exceed 51;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 con'idor 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:
PERIvLIT NUMBER:
HOMEOWNERS SIGNATURE: \ Y
DA'Z'E:
winword/smkdet
• I