R-4659 (2) APPLICATION FOR CITY OF CUPERTINO
MBER PERMIT R— 4659
NU
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM IASTCALLED INSPECTION.
BUILDING ADDRESS C `rI
`-'O( �/-F-tC RESIDENTIAL COMMERCIAL OTHER
owNER \ HAZARDOUS FIRE AREA
J J VES ❑ If yes s I understand that. Class A
NAME scot assembly is required.
INO X Initial LC.B.O.N
ADDRESS T /l W EXISTING ROOF COVERING
PHONE "' J` NUMBER OF EXISTING COVERINGS 1,
CONTRACTOR'S /
TO BE REMOVED TO BE RETAINED
NAME yy IIIAAA L] '
ADDRESS ,(/� TYPE OF ROOF COVERING
CITY&ZIP -�//✓y� I EXISTING
PHONE } I BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECI-ARATION l
thereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 1r�Jfl'�
7000)of Division 3 of the Business and Professions Code,and my license is i till force and
effLicense
2 r WOOD SHINGLES
License Lic.Number ❑
• OTHER(SPECIFY) t ❑
Date � Contractor p� L'b
OWNER-BUILDER DECLARATION PROPOSED NVQ l
I hereby affirm that I am exempt from the Contractor's License Law for the following ason. f/
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to e -
construct,attar,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF �9Ai1-1
appllcant for such permit to file a signed statement that he is licensed pursuant to the provisions (� 19
. of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the r(,`
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES r`Cyg
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
y�/�U
a civil penalty of not more than live hundred dollars($50(1WOOD SHAKES ❑
I,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.7044,Business and Profes-
sionsCode:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,andwho does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.If,however,the building or improvement
Is sold wlthi n one year of completion,the owner-builder wilt have the burden of proving that he did OTHER (SPECIFY) ❑
not build or improve for purpose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 1I/N�
❑I have and will maintain a Certificate of Consent to Performa for Worker's Compensation, BUlldin
as provided is for by Section 3700 OI the Labor Code,for the performance of the work for which this
permit is Issued. So
$QISn11C
❑1 have and will themaintain Worker's Compensation Insurance,as required by Section Worker's
's '
the Labor CCCC��,ppppde,for the performance of the work for which this permit is issued.My Worker's Total
-Carrie, aT�oh:Me cc-rugLjmd Po number are: , 03-52-15
� ^
Carrie, Policy No. /J PERMIT AUTH O DATE
CER FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Op
(This section need not be completed It me permit is for one hundred dollars($t00)or less.)
I certify that In the performance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of car. All roofs hall i spa prior to any r ofing tnateriaf being
lornia. installed. If a roof is installed without first obtaining an
Date Applicant. inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shal0be deemed revoked. Source regulations.
I certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All Ing CI SS"C"or belt e.
hereby authorin representatives of this city to enter upon the above-mentioned property for in. r ---x
spectlee purposes. G
(We)agree to save.indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGN E OF APPLICANT TE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS: -
INSIP DATE INSP DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE 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.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
from the building 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. In order to receive a final,you must complete steps 1, 2, and 3.
1,) Preinspection or tear 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 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 time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY
HOMEOWNERS NAME: \ e 6
ADDRESS:
REROOFING COMPANY NAME:
APPLICANT'S SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rcrooflwinword
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C44 of CUpe►-ti»o
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 requiied.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply. �/ l
ADDRESS: oZ IppYSI c� s t �1 y�*2 A-
PERMIT NUMBER: /,_,•t` ` 3 C 6
HOMEOWNERS SIGNATURE:
DATE:
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