R-4050 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 4050
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
IN DAYS FROM LAST CALLED INSPECTION.
BUILDINNG7 ADDRESS `\^ BUILDING USE
X
RESIDENTIAL - ' COMMERCIAL OTHER
OWNER'S
r - 1 HAZARDOUS �FIRE /yyy---Jl ROOF �
NAME "� AREA •"'� CLASS
COVERING
CJjmQ�
ADDRESS EXISTING ROOF COVERING
Q
PHONE OPVS NUMBER OF EXISTING COVERINGS
CONTRACTOR
TO BE REMOVED TO BE RETAINED
NAME 0 TYPE OF ROOF COVERING
ADDRESS Q g EXISTING
CITY&ZIP
PHONE :3Slol-_27 J7 BUILT-UP ROOF
LICENSE D ASPHALT SHINGLES
NUMBER
WOOD SHAKES !
LICENSED CONTRACTORS DECLARATION
hereby ction 70001 of Division
mo provisions of d Chapter s(comment WOOD SHINGLES
clop who Section]000) of Division 3 of the Business end Professions coda,
and my Inert i do tort red aff«,. O
Liuhe Lia Number
oats conn«tor OTHER (SPECIFY)
OWNER-BUILDER OECLARATI 'N A I �
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED tl
the following reason. (Sec. 7031.5, Business and Professions Code: Any city -`
or county which requires a permit to construct, altar, improve, demolish,or t/
repair any structure,Prior to its issuance,also requires the applicant for such BUILT-UP OR-AV Of519g
permit; heto fila a se's Li ense Law that he r licensed pursuant it the tionprovisions Yy'1
pf the si P 3 of
Business
Law Komar 8 (commencing Code).1In., with S«lion there V
fr Division 3 of the Blot tis and gedfs xem n. or y v he is exempt mare. ASPHALTS INGLfi�.. )N
from and the basis for the alleged exemption. Any violation of Section �N/%•O
]031.5 by any applicant for a permit aub,.c,S the °Oplicant!O is civil penalty I
of not more that five hundred dollars($500).1: WOOD SHAKES
C] 1.as owner of ma properly,or my employees with wage,as their sole
tom panwiion, will do the work,and the Structure is not intended or offered
for"Ie(Sac. ]044, Business and Prof essi...Code: Th.Connector's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
bu idling 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
purposeof Sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, e r of the property, a exclusively connecting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
oda: TheContracto:sLicenseLawdoesnotapplytoanowerofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
cont'actor(s)licensed pursuant to the Contractor's License Law.
reason I am exempt under sap. ,8.6P.C.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dais 11
WORKERS'COMPENSATION DECLARATION Bulldin�
hereby affirm that have.certificate 1 ant n self
copy I er c ater. /� 6�0
Pohl. of Workeri Compensation Insurance r cenif le tlle.aof(Sec. /t $Bl3mIC
3800,Lob.C. G at._(yY �
Policy Ne, by v
tiC C till d copy is hereby lurni( d. Total
'QcCartilied aopYli s a wish m Itv insq*c ,,ddiyi,ipa `
Applicant /.� �YrG �Y/
CERTIFICAT OF EXEMPTION FRO WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for One hundred
bre 1$1001 ortn1ess.l
I el in the performance Ot me Work for which this permit
certify is
issued, I shell not employ any person In any m er ,O e,to become subj«!
to me Workers'Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, H., making this Certificate of Ea°mption,
you should bficome subject to the Workers'Compensation provisions of the
Labor Code.you must forthwith comply with such provisions or this permit All roofsshall be Inspected prlortoany roofing material being
shall be deemed revoked.
I certify that I have fend this application and state that,ba.boy.inform.. Installed. If a roof is installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and Inspection,I agree to rem Ball new materials for inspection
.tate laws relating to building construction, and hereby authorize ep,smm�
btive,of this city to enter upon the above mentioned property for inspection /
purposes. I (GJ S/9�
(We) agree 1.s, ueyedg indemnify and keep harmless themay
City of or ------ r
«ainat liabilities,ludgman[s,costs and expenses which msY In any way accrue
against said City in consequence of the granting of this permit. $IZiNATU/R OF APPLICANT DACE
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 _ _
SUBIECI': REROOFING POLICY FOR TU. CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERNBT AND INSPECTION PHASE.
1. Prior to permit issuance, you nwsl agree to comply with U.B.C. standards and manufacturers spec's
Oil reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from lire building
inspector when [lie reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) Preinspeclion or tear off approval.
2.) In progress inspection approval
• 3.) Final inspection approval.
a.) Operable smoke detector verificaliom
b.) Spark arrestor installation
5. If plywood is installed,a plywood nail inspection is required.
G. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that little.
WE UNDERSTAND TliE ABOVE POLICY ON JIL•11OOFING AND WILL COMPLY WITH THE
POLICY , �D
IION1E-OWNERS NAME:
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Rerool/winreord
Citil of C"perli"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.
1 understand the above requirement and certify that we now have sen Ike detectors
installed that do comply.
ADDRESS: �77 �4 J 6tRl tS C
40
PERNUT NUMBER: T-6
HOMEOWNERS SIGNATURE:
DA'Z'E: 6
i
winword/smkdet
• fi