R-4000 (2) PERMIT R- 4000
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT OINS]PCCE��ICITIOCN DIVISION �1 PERMIT EXPIRATION
(408) 252-4505 EXT, 226 WITHIN 180 DAYS OF IT EXPIRES IF PERM T RK IS NOT
OR
. 100 DAYS FROM LAST CALLED INSPECTION.
�BUILDING
%ADDRESS ��BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS
EXISTING ROOF COVERING
,/ /
PHONE / DOT�p �7"Lo/ NUMBER OF EXISTING COVERINGS /
CONTRACTi
NAME 7 //'�0��"�l I --fes✓G TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
�i STr 'f
DD
CIT&zea� 3 - /y— EXISTING
PHONE T'+ ZnDCF� BUILT-UP ROOF
LICENSE �i ASPHALT SHINGLES
NUMBER p` / 57
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby Nlirm that I am licensee under provisions of Chapter 9(commen-
cing with Section 7000) of Division 3 of he Buonese and Plot...I...Coda, WOOD SHINGLES
and my Ilc.nse b In LII W ntl efbcc i/
License Ie G_3 Lic.Number 7-
Dat. ,Q_ C..,racto, OTHER (SPECIFY)
NER BU.mot from
th
I hereby win affirm cher I . exempt from the dPr Contractor's Licenv Lew for PROPOSED
.1 following reason. (Seca Permit, Businessc ..end Professions Coda: Any city
re air my which re.prior• Perini, to con . alter, improve, demo iauch
repair any structure,prior to its Nuance,abo.a9ulres ane applicant br such gUl LT-UP ROOF
Permit to it le a signed rtatement in.,he is li..nsed pursuant to the provision
of the Contractor's License Lew (Chapter 9 (tpmmencing with Section 7000)
of Division 3 of the Business and Profession C00e1 or that ha is exempt In.,. ASPHALT SHINGLES
from and the basis for the ell aged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
.1 not m.r. he,five hundred d.11.r.($500).1: WOOD SHAKES
❑ I,as owner of the property, or a my employees with wages their sole
..in pemetion• will do the work, andthe structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon, p
and who does such ts ere nes, intended or offered for work himself or through ms own employees,Provided that OTHER (SPECIFY) /�
such improvemensale. If, however, In.
building or improvement sold within one year of c mpletion, the P
builder will nava the burden of proving that he did not build or improve own
�y
purposeof PROVIDE I.C.B.O. REPORT N0. /ee5
C] 1.
as owner of me property, am exclusively contracting with licensed
contractorsto construct the project (Sec. 7044, Business and Professions
Code: The Com rector aLicanseLaw do....I PP y to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Wh0 builds or improves thereon, and who contracts for such projects with a
contractor is)licensed Pursuant to the Contractor's License Law.
❑ 1 em exempt ynde. sec. ,Baso...for this APPLICATION DATE VALUATION PERMIT FEE
owner Date
WORKERS'COMPENSATION DECLARATION Building `
I hereby affirm that I have a certificate of consent to selbinsure,o
of ices..of Workers' pen /5�p sor ancanifiatl co y m of IS '�� $elsmlC ` \�
3900,Lab.. V V� k
Policy Np►r6S oro 7(J [/
�.a.Nnae copy Is eev mmi.ned n A � , � /O� Total
rit I d cop tiled win the ti .tion e'wi cin.
Applicant
TI ICATE OF EXEMPTION FROM WORKERS' N.C.
D ❑ E IT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section naafi not be completed if the Permit is for one hundred dol
jars($100)or les..l /b
I certify mat in the perform.... of he work for which his Permi,
issued, Ianell not employ any person in any manner so as to become subject
to the WPike ri Compensation Laws of California.
Data Ap,licant
NOTICE TO APPLICANT: If, aH., making this Cer,iticae of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or Ill.permit All roofsshala a inspectad prlortoany roofing material being
Niall be domed revoked.I m
I terrify the, neve read this application end state that,he above inrma installed roof is Inst without first obtaining an
tion is Correct. I agree to comply with NI city and County ordinances and inspectio Iagree to rem dal esu materials for Inspection
at... law. roofing to building construction, and hereby autt ie represent
Tives of this city to enter upon the above mentioned Property for inspection
purposes. G�
IWogre. to siva, indemnify costs
and keeexpenses
harmlesswhich the City of Cupertino
:gagain,.jobidilcilty. toms. uo con sod ax.tin, wake may in
ain hid Clev in.ontaouenca of the granting of tins parson.any way acvw 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
SUBIEC'I': REROOFING POLICY FOR TIIE 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.H.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all iuspeclion and written approval
from the building inspector. A final inspection and approval shall be obtained from lire building
inspector wile,, the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
d. In order to receive a final,you pmst complete steps 1,2,and 3.
1,) Preinspection or tear off approval.
2.) In progress inspectiop approval.
• 3.) Final inspection approval.
a.) Operable smoke detector verification
b.) Spark arrestor installatiarr
5. If plywood is installed, a plywood pail inspection is required.
6. If any roof is applied without first obtaining an iuspeclion, you will be required to reprove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND "1'1113 ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
•
CITY OF CUPERTINO
BUILDING DEPARTNIENT
Reroorlwimeord
I
i
Cittj of Ct4per1i1•w
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 sm Ike detectors
installed that do comply. �7 /�J
ADDRESS: �/�/ 0 UC�Pe �re!!le/
PERMIT NUMBER: �— zle 0 U
HOMEOWNERS SIGNATURE:
DATE: / 7
winword/smkdet