R-3921 (2) i
PERMIT R_ 3921
APPLICATION FOR �� GITY-OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
ROOF
NAME / IJCYJ �' `�!� y '/ FIRE COVERING COVVERING
c AREA CLASS
ADDRESS (e.�G�/�e/ EXISTING ROOF COVERING
PHONE d �-�S NUMBER OF EXISTING COVERINGS
CONTRACTOR'S//�p .J�i/y
NAME /Tu �L.-y Chi / /C/D ��'/YJ TO BE REMOVED TO BE RETAINED
/��/ TYPE OF ROOF COVERING
CITYRESS �(a / ST S-T' vG
EXISTING
PHONE
✓/U ''r<<,l7 ;76D.? BUILT-UP ROOF
LICENSE9.� ASPHALT SHINGLES
NUMBER / WOOD SH KES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter v(common WOODS INGLES
.in, with Section 7000) of Division 3 of the Business and Professions Cod.,
and my,license ie In II Ip and affect. /J�/)5/�
LI<anw Cla Lk.Numba• 7 / OTHER ( PECI,�Y)
Data
Conerecto. - ,y ^`
OWNER-BUILDER OECL ION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the county
flowing reason. (Sec. )Orli, o clnesF end Profssimpr Coda: Any cityg
dr cf flo WhieM1 reqon. iresSe a parmil td constsnan uct,and alar,sion$Co,e: An city
rap.lr any structure, prior to in issuance,also requires the applicant for such BUILT-UP OOF
Penn it to fib a signed statement that he is licensed pursuant to the Id.islom
of the Contractor i License Law (Chapter g (commencing with Section 70001
fro Division 3 of the Business and gProfession,xe tion. or inn tea is exempt here ASPHALT S INGLES
from and he basis for [ha ellepetl exemption. Any violation of Section
7031.6 by any applicant far a pmmrt subjects the applicant to a civil penalty
of not more that live hundred dollars( 500).): WOOD SHAK
❑ I,as owner of the property,or my employees with wages as[heir sole
compensation,will do the work,and the structure is not intended or offered yy00D SHINGLES
for sale(Sac. 7044, Business and Pronssions Code: The Contractors License
Law does not apply to an owner of property who buildf or mprove%thereon,
and wnq dem such work himself o,through his own ampeovem,provided that fOD
such imp•ovemen[s ere not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or.improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for
pulp....,sale.). PROVIDE I.C.B.O. REPORT NO.
[:] I, a of ma property, a exclusively contracting with licensed
contractors to construct Th. project (Sac. 7044, Business and Professions
Coda: The Contractor's License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds of
improves theraun. and who contracts for such projects with a
cant sctorbl licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C, for this
reason P CAT N DATE VALUATION PERMIT FEE
own., Date
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have certificate of consent to salt insure,o
3800[a OIW �Ompep.7 insurance, aCartiliaa<opr sofa F V 81995 /D��O Seismic
3800,0101 -/C R
P011cy N party
red coo hereby furnish Total
E co T,fiatl Hied w,N tat' action division. CID UF' GurEH IINU
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.❑ PERMIT AUTHORIZATION DATE
COM
PENS TIONmillet INSURANCET4L
(This section need not be completed it the permit is for one hundratl tlob i4e,
bra($100)or n., i
certify tnat in the performance person
of ny work for as to 'his
parmil if
001
sued, 1 onkel not employ any Lenon In any manner so as t0 become subject
to the Workers'Compensation Laws OI California.n
Date Applicant
NOTICE should
APPLICANT: o atter making [his ansa iiinp of Exemption,
you should Deco ma subject i h c Workers' Compensation provisions of the
Labor Coda.you must forthwith comply with sato Drovisions or lois parent All roofs shell be Inspected prlorto any roofing material being
.hall be seemed rwoked.
1 certify that 1 have read this application and stab that the shove informs. Installed. If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with au city and county ordinances and Inspection,1 agree to removeall new materials for inspection.
%lab laws seating to building construction, and hereby authorize rapmen
[olives at this city to enter upon the above mentioned Property for inspection
purpose..
(Wo) agree to save, indemnify and keep harmless the City o1 Cupertino
aninn liabilities,judgments,costs and expanses which may in any way accrue
agsint said 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
SUB1ECf: REROOFING POLICY FOR 771E CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you umsl 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 buildiug 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. Iu order to receive a final,you illus(complete steps 1,2,and 3.
1,) Preinspeclion or[ear 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.
6. If any roof 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 shcalhing at(hal lime.
WE UNDERSTAND 771E ABOVE POLICY ON REROOFING AND WILL COMPLY WITH TM'
POLICY
HOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPAJITMENT
RerooVwinword
1 r
i
i
CitN of Cupertino
SMOKE DETECTOR CERTIFICATE Or COMPLIANCE
1 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 sin Ike defectors
installed that do comply.
ADDRESS: /0 3�Z S��-2iG
PERIvUT NUMBER: 3 / Z
HOMEOWNERS SIGNATURE:
DATE: .
d- 1�12 Cil L ��
winword/smkdet i