R-3901 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R3 9 01
-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 WIRMIT EXPIRES IF THIN IN DAYS OF PERMIT RK IS NOT
OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS WILDING USE
/ 7 / Qt.,Do ! /' w` RESIDENTIALCOMMERCIAL OTHER
OWNER'S d
NAME
HAZARDROOF
!!1 /7 Ni rl Dreher FIREAREOUS COVSESRING
LA
ADDRESS
14-7 7 80 EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
'
CONTRACTOR'S
WagnerTO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CIITDY&2i6 , O-BOY-_, S'S 1`ton+e Serev�oS EXISTING
PHONE 777-5-.:ivs( BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
Ihereby affirm that I am licensed under provisions of Chapter 9(common
ting with section toxo) or Division 3 of the Business and Prrolessions Code, WOOD SHINGLES
and my license1 JR iuq force and efiece -72.-1 Z
r (o
Data Ch
License Cl as C 'S s'1 oNumbs
D
. otrecm. OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lawfar PROPOSED
the following reason. (Sec. 7031.6, Business and Profession.Coda: Any city
or county which requires s permit to construct, alto, improve, damolith,or
repair any structure,prior to its issuance, also requires the applicant forsucn BUILT-UP ROOF
Permit to file a signed statement that he if licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Prafe,tiuns Codel or met he if exempt more
ASPHALT SHINGLES
from end the basis for me alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more mat five hundred dollars($500).1: WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages as their sole
com pensabon, will do me work,and me structure is not intended or offered WOOD SHINGLES
for sale (Sec. 70,14, Business and Profession. r Code: The Contractor s License
Law does not apply to an owner of proper who builds or improves thereon, / L ('
and WM1O does such work himself Or�ht
4n .'
own emplOyaaf,pravitletl that /`, r e�
cath improvemanu e.e not i and for sale. Ir, However, m° OTHER (SPECIFY) ,
building or improvement is s or
of com Dletion, me owner
buile.r wise nave ma Du men p not baud or improve for
purge..of..l..l. PROVIDE I.C.B.O. REPORT NO. 81k Lu'�a0
❑ I. al owner of me Op tVNilly convecting with licensed
contracton to construct a proja . 7044, Band Profession.
ode: The Contractor t L cense L not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
wno build$ or improves thereon, no who contracts for such project.with e
contractor(f)licensed pursuant to the Convector's License Law.
reason 1 .m exempt under sec. ,e.a P.c.foe his APPLICATION DATE VALUATION PERMIT
Owner Data e-e a ____
//� r
WORKERS'COMPENSATION DECLARATION 0 BUllding
I hereby affirm mat I have a certificate of consent to sal linauro,O C
tificau of Workers'Compensation Insurance,or certified copy thereof ISea /7 Seismic
Is L.b1 In4Q9 R5 5kG�2 eP etl 9
Policy Lab U Company UVbC x
.J
"Certifi'ea c v t hereby carni. (/h �Total
p.c.ruri. rn will,t .k.–t. s ri is (1Ul.+�k
App meso •-
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHO DATE
COMPENSATION INSURANCE
(This section need not be completed it the permit is for One hundred dol
lar.($1001 or Ins.)
I Certify that In the performance of the work for which this permit
ClI shell not employ any person in any manner so as to become subject
to the Workers'Compensation Lew,of California.
Data Applicant
NOTICE TO APPLICANT: If, eft., 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 prlortoany roofing materialbeing
shall be deemed revoked.
I certify that I have road 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 all city and county ordinances and inspection,I agree to remove all new materials for speCSIOR
state haws relating to building construction, and hereby authorize reproush
,olives of this city to enter upon the aboyeYnandoned property for inspection
purposes.
(We) agree to Save, indemnify and keep harmless the City of Cupertino
.9sinit liabilities,judgments,costs and expenses Which may in any waY accrue QQQ
against said City in consequence of the granling of this permit. SIGNATURE OF A PLICANT D —�
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL
3 INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on 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 the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2,and 3.
I,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
• a.) Operable 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 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 time.
WE UNDERSTAND TIME ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME: ms- vgeketL
ADDRESS: /4? 9 iso OPy w�/
REROOFING COMPANY NAME: �C GYIPJ�
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroofhvinword
t
Citiq of CUpertitso
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.
ADDRESS: Y47 1120 OPy (til 4 y
PERMIT NUMBER: ��-(3�U �-
HOMEOWNERS SIGNATURE: /` - -N"�% �- - �' ''• -
DATE:
I
winword/smkdet
I
•