R-3976 (2) PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER R- 3976
REROOF PERMIT OINSPECTION DIVISION p PERMIT EXPIRATION
(4O8)ZJZ-4JOS EXT. GLV ORK IS NOT STARTED
PERMIT
180 DAYS OPIRES IF F PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING i9into
BUILDING USE
to RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAM FIRE t( COVERING
AREA r+ CLASS
ADDRESS
Q EXISTING ROOF COVERING
l I NUMBER OF EXISTING COVERINGS
PHONE L
CONTRA�{?�Q 'S
NAME ^ ILL— E!- ' IZ1 ) E F Inv t,(_7y1a'7 TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS p EXISTING
PHONE BUILT-UP ROOF
LICENSE ASP GLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chanter 9(commm�
ing With Section 7000) of Division 3 of the Business and Professions Coda, OD SHIN
and my license Is In full force and effect.
License CleatLic-Number OTHER (SPEC Y)
Det. Contractor
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Connector's License Low !or PROPOSED
the following reason. (Sec. 703 1.6, Business and Professions Code: Any city
or c linty which requires a permit to construct,alter, improve, demolish,or
repair any structure,prior to its issuance, also requires the applicant for such BUILT-UP
permit to file a signed statement that he Is licensed pursuant to the provisions
o1 the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt there SPHALT SHINGLES
from and the bells for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects me applicant to a civil penalty
01 not mon that five no ndred dollars($500).1:
❑ I,as owner of he property, or my employees with wages as their sola
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Cada: The Contractors License WOOD SHINGLES
Law does not apply to an er of property who builds or improves thereon,
and who dose such work himself or through his own employees,provided that
sec^ improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is told within one Year of completion, the owner
bing that he did not build or improve for
I
PROVIDE I.C.B.O. REPORT NO.
e f owner of the property, am exclusively contracting with licensed
c0 nG
to to construct the pr0%ect (Sac. 7044, Business and Professions
•: Tn.comeecto:aLi=Bns. L.endo.+nm.pproto.npwn..plp.pp.rty PROVIDEMFGR. INSTALLATIONSPECS.
w Crd builds or improves thereon, and who contracts for mc^ projects with
ractor(s)licensed pursuant to the Contractor's License Law.
❑ am exempt undo. se=. ,Bed P.C.for this PPL ATION AT VALUATION PERMIT FEE
own. Dat. ry
WORKERS'COMPENSATION DECLARATION ^// R [J� BUlldin
I hereby affirm that I have a certificate of consent to seR-insure,or a car. {. ei
[iliceta of Workeri Compensation Insurance,or a certified copy thereof(Sec.
r n Seismic
3804 Lab.C.1. G�LU t7
Policy No.Certified
Company LI/�I1 Total
8 Certified copy is filedhelob,w lu mins ed. ~Cti ``�/
Certified copy if filed with[M1e city impaction division. �/I/
Applicant /•O
CERTIFICATE OF EXEMPTIONFROM WORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE
COMPENSATION N S URANCEZ7
(Thissection nand not be completed it ma permit is for ossa hundred dol
I...(5(510 ✓
00)or that
i
m
I certify et me performance of the work for which this permit is
seed, I shall not employ any person any manner ail as til become tublect
to the Workeri Compamesion Laws o1 Glifornie�n
Data Applicam
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption,
Vow mould become subject to the Workers'Compensation provisions of the
Cache.you id ievoked.menet forthwithforthwithcomply with such provisions or this permit
,hall be deemed All roofs shall be inspected prior to any roofing material being
shall
I certify that I have rend this application and state that the above informs Installed If a roof IS Installed without first Obta' ing n
tion is correct. I agree to comply with all city and county ordinances and Ina @COIOn�I agree to re OVB all w mater'alsfor i ect R
state laws relating m building construction, and hereby authorize rso as eo P g p
atives of this city to enter upon the above-mentioned property for inspection
purposes. ..
(Wal agree to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,casts and expenses which may in any war accrue
.Winst said City in consequence of the granting of this permit. SIGNATURE OF APPLI NT UrATE
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
SUBJECT: REROOFING POLICY FOR '1'11E CITY OF CUPERTINO BUILDING DEPARTMENT
PR10R TO ISSUANCE OF PERIvWr AND INSPECTION PHASE.
1. Prior to pencil issuance, you umst agree to comply with U.D.C. standards and manufacturers spec's
Oil reroofug.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
Flout [lie building inspector. A final inspection and approval simll be obtained front the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. Ill order to receive a final,you must cmuplete steps 1,2, and 3.
I,) Preinspectiou or[ear off approval.
2.) In progress inspection approval.
• 3.) Final Lnspecliou approval.
a.) Operable smoke defector verification
ba Spark arrestor installation
5. If plywood is installed, a plywood nail iospectiou is required.
G. If nuy roof is applied without first obtaining mr inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that lime.
WE UNDERSTAND TILE ABOVE POLICY ON REROOFING AND WILL COMPLY WI'III THE
POLICY
IIOMEOWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME: nl-Q
' I r
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
• BUILDING DEPARTMENT
' � r
Reroof/wvn n o d
i
AdmkA
I -
Cittl of Cupet-ti"O
SMOKE DETECTOR CERTIFICATE OF 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 sm Ike detectors
installed that do comply. ///��: �
ADDRL•SS: X el-0 VC/ o �n L/P�rx_. i �r . rl —moo
PERMIT NUMBER:
R - 3 �
HOMEOWNERS SIGNATURE:
DA'L'E: &A f S
winword/smkdet