R-4138 (2) PERMIT R_ 413 8
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 1 BUILDING USE
L %r-k WD d Dr. RESIDENTIAL COMMERCIAL 1 OTHER
—
OWNER'S
IYS Q�7 ^
NAME (Ir, rr\,•/ 1 0Y)PrrYY1Ln. FIREARDOUS VY) COVERING /1
R
AREA CLASS
ADDRESS ID 19 5 R icku lc)nj n'r. EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
\�� Qh�9� TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CIOTDY&Zib Po SpX3C!5J3--� (\AOn-1-P SPXP((1(/ EXISTING
CA. 4�v3O
PHONE 777- X331 BUILT-UP ROOF
LICENSE �C ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 I<omman-
ping with Section 7000) m Dlvbion 3 of me Business end Professions Coda, WOOD SHINGLES
and mY liceqnse i. /u a and Of. t �.I �--�
License_:3 — s1 r` Lic.Number ` OTHER (SPECIFY)
Date Contractor
OWNER BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following.anon. (Sac. 7031.6, Business and Prof au ions Coda: Any city
or county which requires a permit to construct,alter, improve, demolisn,or
repair env arvctun,prior to its issuance,also requires the applicant for ch -UP ROOF
P.= to ilia a signed statement that he is licensed pursuant to the provissui0nf BUILT
of the Contractor'. License Law (Chapter 9 (commencing witn Sytion 7000)
' of Division 3 of the Business and Proiy....,Code)or mat he I....mpt ther.. ASPHALT SHINGLES
from and the basis for the alleged ..emotion. Any violation of Section
7031.5 by any Appl lent for a permit ubjec is tha spin l is ant to a civil pan al ty
0i not more that five hundred dollen($500) .1: WOOD SHAKES
p 1, as owner of the property,0,my employees with wages as their sole
compensation,wilt do the work, and In.structure is not intended or offered
for at.
(Sec. 7044, Business and Profession.Coda: The Contractor's License WOOD SHINGLES
Law don not apply to an owner of property who builds or improves thereon,
and who don such work himself or through his own employees,provided that
such imp.ovemann ere not intended or offered for sole, It, however, the OTHER )SPECIFY) �jQ rvLWUao7
building or improvement i sold within one year of completion, the owner
builder will have he burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
O I, as owner of the property, am ..elusively contracting with licensed
contractors to c nstruct the project (Sec. 7044, Business and Professions
Coda: The ContractorILicense Low does not apply toonowner ofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves tharwn, and who contracts for such Projects with a
contractors)licensed pursuant to the Convectors License Law.
O 1 .m exempt send.. s.p. ,Bea P.c.for this APPLICATION DATE VALUATION PERMIT FEE
owner Data 6
WORKERS'COMPENSATION DECLARATION ix//'• ® 8: Bulldin
I her.by affirm that 1 have a certificate of consent to.elf.insufe,c C VV
tificate of Workers Compensation Insurance or a c�rtilietl coPv thereof(Sac. C� $el$mIC
3800,lee 1 J h g9 1
Policy N�l�1bSG4-95Dompanv •��U'�P
O�c n+iedfff�eogwvv��J.harebv furni L 9L� Total
9"c.air. n t e mp` _on. 4 J
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' �— PE1'IM IT AUTHORIZATION DATE
COMPENSATION INSURANCE N•C
(This section need not be completed if the permit is for one hundred not
Ins($100)or Ins.)
I certify that in the performance o1 the work for which this permit is
issued, shell not employ any parson in any manner so as to become WbjeCI
t0 the Work. Compensation ie
Compensation Law.of cilifpm ,
Date Applicant
NOTICE TO APPLICANT: It. after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor cod.,you must forthwith comply with such provision.or his Permit
shell be doomed ravokad. All roofs shall be inspected prior to any roofing materiel being
I cvtify inn 1 neve read this application..it stet.that the above inforina. Installed. If a root is Installed without first Obtaining an
tion is Correct. 1 agree to comply with all city and county ordinances and M?zrr4?
n,l gag ree to remove all new materials for inspection,
state law. relating to building conaructioq and hereby eumori,. r.pr...m
tatiws of this city to m[er upon the eb Ovamentionetl property for inspection
PurPo.es.
IW 1 agree 1.s. sew, indemnify and (rasp asharmlessWhich ha city of Cupertino
against liabilities. consequence
cents end e.penys which may in my way accrue
against
said city ld mnwquanpa of the gaming of this permit. SIGNATURE 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 _-_
SUBJECI': REROOFING POLICY FOR 'TIIE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNUT AND INSPECTION PHASE.
1. Prior to perwit 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
front the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is couhplcicd.
3. All types of roof shall be inspected prior to ally roof being installed.
d. In order to receive a final,you"lust complete steps 1,2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verilicalia"
b.) Spark arrestor installation
5. If plywood is installed, a piywuod nail inspection is required.
G. Ir any hoof is applied without first obtaining all inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at Wat lime.
WE UNDERSTAND THE ABOVE POLICY ON 11-CROOFING AND WILL COMPLY WITH TILE
POLICY
HOMEOWNERS NAME: VIC 1-erC n krl erw,rsin
ADDRESS: Intu� Rif 6xic7t_DA Qy-
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
•
CITY OF CUPERTINO
BUILDING DEPARTMENT
RerocU% imeord
i
,V
I
Citi, of Cupertino
SMOKE DETECTOR CERTIFICATE OF COIv(PLIANCE
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 51,000, a smoke
detector will be installed, mounted oil 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 sm Ike detectors
installed that do comply.
ADDRESS: W0 -iS Rirkwooci �)r
PERMIT NUMBER: — LI I �J n
HOMEOWNERS SIGNATURE:
DATE:
I
winword/smkdet
J
J
I
•
J
fill,
•