R-3742 (2) PERMIT R- 3742
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT.EXPIRES IF WORK IS NOT STARTED
.(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDIN�G1/ADDRESS
/,}�( BUILDING USE
I �I
IS, / 1 l OS L H �a-1 C. ��• RESIDENTIAL--& COMMERCIAL OTHER
OWNER'S
NAME L �`7s -res FIRE HAZARDOUS COVERINGARE
ADDRESS nS/-JR'M EXISTING ROOF COVERING
PHONE / L 1 D NUMBER OF EXISTING COVERINGS
CONTRACTOR'Sn • ,/ TO BE REMOVED TO BE RETAINED
NAME aj/T� 'Ron F1& 4/i�, TYPE O ROOF COVERING
ADDRESS �O ('�X7. 963 `rry CJ$UO9 EXISTING
PHONE 2 / BUILT-UPROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licenud under wovisian.of Chapter 9(common
ing with Section 70001 f Division 3 of the Business Proaa.ion. C.
WOOD SHINGLES
and my licanq p wfull-b and aHacc [/ /
License fel i .� Llc.Numbere;?1; 7 10 OTHER (SPECIFY)
Dst. — Conbac for
OWNER-BUILDER DECLARAT N
1 hereby alfirm that 1 am exempt from the Contractor. Licenu Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
county which requires a permit to construct, slur,improve, tlamolish,o,
re
pair any structure, prior to its issuance also requires the applicant for such BUILT-UP ROOF
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9 (commencing with Section 7000)
' of Division 3 of the Business and Professions code)or that he is exempt there ASPHALT SHINGLES )
from and the basis for the alleged ..e mptio., Any violation of Section
7031.5 by any applicant for a permil subjects the applicant to e civil penalty
of not more that live hundred dollar.($500).): WOOD SHAKES
❑ 1,as owner of the property,or my employees with wages as their sole
compensation,will do the work, and the structure is not Intended or offered
for sale (Sec. 7041, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does 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 un
provemenn are not intended or offered for sale. If. however, the OTHER (SPECIFY)
bu Ndi ng or improvement is sold within one Year of completion, the owner
builder will have the burden of proving met he did not build or improve or
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an Owner of property PROVIDE MFGR. INSTALLATION SPECS.
-no builds or improves mereun,and who convecu for such projects with e
contractor(s)licensed pursuant to the Contractors License Law.
❑ 1 em ...mut under S.C. ,B.&P.C. for his
oasts. Dote
APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION 1, 9 /,D I Bui ding
I h...by.farm mat I nave a certificate of consent to self4nsure,or a car V
oficaI.o1 Wo.ken'ComLeftpensation Insurance,o.�/canuied copy thereo`f sec. /�/} /,�l/ 0°' Sal I
3800 No 1.9 LCompenv �Tr1 • `--' �y/�11_ �,l1A e / 0o ' Total s
�Certified copy is hereby Turn. In d. kJ751�
CeItifiad Cp ( LledlYith tfty[fty �z 1 Op.
Applicant Tl/C/ U.C(111� lea. rL�.0/C.C.
will
CERTIFICATE OF EXEMPTION FROM WORKERS' N
COMPENSATION NSURANCE C ❑ PERMIT AUTHORIZATION DATE
(This section need not be completed it the permit is for one hundred dol
bat($100)or less.)
I certify that in the performance of the work for which this permit is
ipuad, 1 shall hat amplay any person in mn
y manner so es to become subject L/
to he
Worxis Compensation Laws of California. I.
Date Applicant
NOTICE TO APPLICANT: Il, eH., making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Coda, you must ferlhwilh Comply with such prevision+.r this permit
shall be deemed revoked. All roofs shall beinspected prlorto any roofing materialbeing
I certify that I nava read this application and.tau the,the above inform. installed If a roof is Installed without first obtaining an
nen is correct. 1 agree to Comply with all City and county ordinances and inspection,I agree to remo II new materials for inspection,
sesta laws raining to building construction, and hereby authorize repreea.n
tnives of this city to anter upon the above-mentioned property for inspection /1 se -
purpo
IWogres to Gave, indemnify and bap harmless the City of Cupertino
against liabilities,judgments,costs and expenses which may in any way aCClus.
' against amid City in consequence of the granting 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
• SllU1GC'I'; III:IlOOPING POLICY 17011 •1111; CITY Of CUI'EICI'lIJO UUILDIIJG ULPAIII'MLNT
I'IIIOIt'I'0ISSUANC1 017I'fllMl'I' AND INSI'GCI ION III IASE
1. Ihior to permil issuarlcc, you nwsl aglcc to cdmply (villi U.U.C. sl""dards "lid nl°°ufaclulcls spcc's
on reroofing.
11
hokil
2. N.oln 111 of boitding inspector.not e flu all illlspcelton sn(lt opplovalgs1 11beobloimed Goll, the builiJ iag
inspector lehen the 1croofing is completed.
J. All lypcs of loaf shall be ilispccicd prior to any roof being imslallcd.
4. In order to lcccive ri lin:d, you WWlsl coruplcle steps 1, 2, rind J.
I,) 11rciuspcction or tear off:lpprov:d.
2.) 111 piogress inspccliou Wpprov:d.
1,) Proal inspcc ion :lpprov''I.
Opciablc snlot(C(ICICC(01'vcrific;11ion
b ) Sl):Ill( ril lcsior Illstallatloll
5. If plywood is inslallcd, ri plywood Will inspccliou is rcquilcd.
G, If ;illy roof is applied lvillloul first oblaiuiog nn inspccliou, you )vill be rcgililcd to remove all ncly
nu;lLly 1l 0f isdowto the sllc;dbilig and :l building iuspcclor will inspect all sheathing at that lime.
AND WILL COMPLY WITII *111-13\N1: UNDERSTAND 'III[, AIIOVE POLICY ON REROOFING
POLICY /
IIOMI:OWNEItS NAME::.
ADDIl1:SS:
AJ, Roo FI AJ
It[iltOOhING COMPANY NAME: D ,, 11
At)PLICAN'I'S SIGNA'fUltli: � GtJ �2ti
CITY 01' CUI'EIt'I'INO
UUILUING DUI'AICI ML•NT
•
ItclooUlvillwold
Cita of Cwpcl 0110
1'.0.13OX 500
10100 1iw r.wcnur. - Cupcillnn.CA 95015.0500
Ggrt,lino.CA 9,r)01,1-3255
-[Ocphnoc: 1400) 252-4505
rAA: (4011) 252-0753
COMMUNI ry UCVCIOPMENr
SMOICI's�I 1_LC'fUlt C[ It7ll_ICATC OF COMI'I IANCL
I rulderslandand comply with Section 1210-a of the Uniform Building Code.
Section 1210-a requires when repairs to a single family dwelling I. ' fe111$11001 a11 moke
detector will be installed, 1ou11ted 011 the ceiling or wall ill each 1 g
point cenlrally located in the corridor or arca giving access to 100111 used for sleeping
• pul poses. if existing smoked dcleclors comply, no new detector shall be required.
I understand the above requirement and certify that we now havd, smoke dcleclors
installed plat do comply. 7L �
ADDIU SS:
2 - 3 ' x/ 2
PERMI"I' NUMUCR: � "
IIOMI?OWNERS SIGNATURE: '
DATE:
winword/snllcdel
r I �