R-4042 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Roa 4042
REROOF PERMIT �1w NSPECTION DIVISION PERMIT E
PERMIT EXPIRES IF WORKORKIS NOT STARTED
(408) 252-4505 EXT. 228 IDAYSPERMIT ISSUANCE OR
IN B0 DDAAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWN R'S � �'
Sff//�I�y.. 7 GuoorK� OUS HAZARDROOF
NA E FIRE COVERING
AREA CLASS
ADORES L�� /V> --+•7"•�� PL. EXISTING ROOF COVERING
PHONE 7�-�� ZS Z NUMBER OF EXISTING COVERINGS /
CONTRA/c��oR'S TO BE REMOVED TO BE RETAINED /
NAME /1 /�K—O TYPE OF ROOF COVERING
��
DD
CIT&isa �� Z ��/y��• EXISTING
S!, /
PHONE ~ JC60 4r9 /p✓/J Z BUILT-UP ROOF Y
LICENSE / L, J � y�y�3B ASPHALT SHINGLES
NUMBER C-� T o WOOD SHAKES ✓
LICENSED CONTRACTORS DECLARATION
I haseby affirm that I em li< head under prpvisicne of Chapter 9(comma. s
cin, with Sac tion ]0001 of Division 3 of the Business and Prof...ions Code, WOOD
.no my uea.. a�q�UlLf a and efface (�7a-
Do,.
f S
License Claes G .i Lic.Numb.
Dm �¢ Comractor O ER (SPECIFY) /1
xx 0ANT:R-BUILDER DECLARATION < '
I hereby affirm that I am exempt from the Contractor. License Law for ROPO E
the touowing reason. (Sec. 7031.5, Business and Prof an ion.Code: Any city /s
or county which requires a permit to construct,alter, improve, demolisn,or
• repair onv amctu res,prior
;o its issuance.also requires the applicant for such BUILT-UP OF [
Perm to Isle s signed statement that he a licensed pursuant to the Provisions
of he Contractor's License Lew (Chapter 9 (commencing with Section]0001
of Divi.ion 3 of ma awl ane Prmenions code)or roar fie i.exempt there AS N S
• from and ha brie for [M1e alleged exemption. Any violation o1 Section
7031.6 by any applicant for a permit subjects the applicant to s civil Panel',
of not more that live hundred dollars( 5o0).): WO HAKE
❑ I,as owner of me property,o my employees with wages a their sole
compensation,will do me work,andthestructure is not intended or offered WOOD INGLES
for sale (Sec. ]044, Business and Professions Coda: The Contractor's Licenses
Lew does not apply to an owner of property who builds or improves thereon,
and who does such Work himself or thrown his own employees,provided that
bLien Improvements . no[ intended or offered for sale. If, however, the HER (SPECIFY)
uilding o improvement I sold within one rear of completion, the owner
builder will nava the burden of proving that he did not build or improve for
pulp...of algid. PRO IDE LC.B. . REPORT NO.
❑ 1, as owner of the property, a exclusively comractin,with licensed
contractors to construct the project (Sac. 7044, Business and Profession$
[ode: The Contractors License Lew does not apply to on Owner Of property PROVIDE MFGR. INSTALLATION SPECS.
who build$ or improves theroun, and who contracts for such projects with +
contrector(s)licensed Pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,8.&P.C.for this
Date
APPLICATION DATE VALUATION PERMIT FEE
o
Owner WORKERS'COMPENSATION DECLARATION Building 6 If
I hereby alfirm that I neve a certificate of consent to self insure,or a card I
tili<ate Of Workers Compensation Insurance,or a certified copy thereof ISec, f
fill Lob.C.1. �% f • Seismic
Policy No. Company pa
I7Certified cop,is hereby fur ni$had. AR (t Total
Certified copy is filed with the city impaction division. (j f7 'r r.
Applicant / 1 A
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ L f r ff� PERMIT AUTHORIZATION DATE
COMPENSATION I N S URANCE
(This action need not be completed if the permit is for one hundred dob r �K I IryV
Ian(5100)or In$.) •e✓�
I certify that in In
performance of the work for Which [his permit is -
issued, I shall not ampl oy anY parson in any mann V`)manner s0 a to b...ma$ubi.1 "al
to the Workeri Comp.nu[ion Laws of California,
Dees Applicant
NOTICE TO APPLICANT: If, altar making this Certificate of Exemption,
You should become subject to the Workeri Companation provisions o1 the
Labor Code, you must forthwith comply with such provision$or his permit All roofs shall be inspected priortoany roofing materiel being
.hall be deemed revoked.
I certify that I have read this applice[ion and nele the[the above 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 InSpe ion,I to remove all new materialsfor inspection.
state Laws relating to building construction, and hereby autno'ass loplaon.
tativee of this city to enter upon the above'mentioned property for Inspection
purpose. �/ 7
. Iwo agree to sea, indemnify and keep es which he City of Cupa.i no Z.
against liabilities, consequence
cosh and expenses which mem in any way accrue
25
against said City m conagwnpa of the granting at this Permit. SIGNATURE OF APPLICANT ATE
.� 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 TILE CI'T'Y OF CUPERTINO BUILDING DEPARTMENT
PRIOR T'O ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to penuit issuance, you mus, agree to courply 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 ,Ire building iuspeclor. A final inspection and approval shall be obtained from the building
inspector wire,,lire reroorrng 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. '
l,) Preiuspectiou 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 uail iuspecilorr is required.
G. If any roof is applied without first obtaining au 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
110MEOWNERS NAME: SlIe
e
ADDRESS:
REROOFING COMPANY NAME:
APPLICANTS SIGNATURE:
. CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/wimvord
Cites of Cupertino
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.
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE: ✓� a
DATE: � 6
winword/smkdet
• i