R-3622 ph�� 'C7cuwei+..,
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— '31622
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
^ Q�
ADDRESS n �p BUILDING USE
l d O%�^IdO -4,,,,/ Cot.— RESIDENTIAL COMMERCIAL OTHER
P!
OWNER'St/�yIIy'Qn•L) ,/ ROOF
NAME . R. 91' (L1 41 CY-• i(7h/0.•GtJ0..MtJ FIREARDOUS COVERING
AREA CLASS
ADDRESS &I EXISTING ROOF COVER
pING
NUMBER OF EXISTING COVERINGS
PHONE OaS-6- .2V( Yoh- aSz-a
CONTRACTOR'S -
�j u�J TO BE REMOVEDy TO BE RETAINED
NAME CX - TYPE OF ROOF COVERING
CITY a ZIP EXISTING
PHONE BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD HAKES a
LICENSED CONTRACTORS DECLARATION n Epp Lia E ® IN it
J hereby affirm 7000 I of licensed 3 of t provision,of Chapter s(nommen P I�\l /,—
andwith Section is I TooD)force Divisionnof 3 of 7n.Business and Prp,..eipn,cud.. WOOD SH I GL'ES r
and me license is In toll fomund affect. I\.'i h P U 'T
DataCl.- Li<.Number 1 'LI
DateContractor OTHER (SP 'IFY)
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractors License Lew for PROPOS
the following reason. (S«. 7031.5, Business and Professions code: Any alto
Or county Whichrequire, a permit to construct, alter, improve, demolisn,or
repair any,trucmto, prior to in issuance,al..requires the applicantfor,uch BUILT-UP ROOF
permit to fila a signed statement that be is licensed Pursuant to the provision
of the Contractors License Lew (Chapter 9 (commencing with Section 7000) 7�
Of Division 3 o,the Business and Profession Code)of me
et he is exempt mere. ASPHALT SHINGLES ✓ J
Lo-
from end the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant,or a Permit subjects the applicant to a civil penalty
of not more that five hundred dollar,(asom.): WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their sola
ompensation,will do the work, and the structure is not intended or offeree WOOD SHINGLES
for,ale (Sec. 7044, Business and Professions Code: The Contractor's License
Law 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
offeree for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year o,completion. the own.,
builder will have the burden of proving that he did not build or improve for
purpneof sale.). - PROVIDE I.C.B.O. REPORT NO.
[31, as owner of the property, am exclusively contracting with licensed
contractorsto construct the project (Sec. 7044, Business and Professions
Code' The Cont ai License Low does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves theraun, and who contracts for such Projects with e
contractm(sl licensed pursuant to the Contractor's License Law.
❑ 1 em exempt uncle. sec. ,8.6P.c.for this
eason APPLICATION DATE VALUATION PERMIT FEE
Owner Date p�
WORKERS'COMPENSATION DECLARATION P 1, 11 D Building
I hereby affirm that I have a certificate of consent to self insure,or a car
tiffnate of Workers' Insurance,or a certified copy thereof(Sec. Seismic p
PoliMAY 31994 so
Policy No.y Na. Company p.7
BCertified copy is hereby furnished. Total !Ze
Certified copy is filed with citthe city inspection division.
Applicant nl -
YH
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. [3 `PERMIT AUOFIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol. �Q�J /9 Jt,��-k,�-L,i(/QGr• p !`/(��/��
IOrs(5100)nr Iess.) J
I certify that in the performance of the work ,or which this permit is
issued, I shall not employ any parson in any manner so as to become sublact
to the Worker,'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption,
You should become Subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit - All roofs shell be inspected prior to any roofing material being
shall be deemed revoked.
I Camay that I have reed this application and state that the above informs installed If a roof Is installed without first obtaining an
run is correct. I agree to comply with .II city.ata county grain« as end inspection,I agree to remove all new materials for inspection,
state lave relating to building construction, and hereby authorize re
inives of this city to anter upon the above mentioned property for inspection �} //(n/ ^.
we) agree a ave, indemnify and keep harmless the City of Cupertino
31
against liabilities,judgments,costs and expenses which may in any way accrue
against 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
REROOFING POLICY FOR 1111; Cl I Y OF p,ER'17N0 BUILDING DEPARTMENT
SIIUJLC'I'; .
PIIIOR'I'0 ISSUANCE OF I'GRMI'I' AND INSI LCI IOIJ PUASC
I. Prior to peami( issuance, you null agicc to concply with U.D.C. standards and mamifaclo(ars spces
on reroofing.
n and
2 Nckv Flom ctlof bo l(liug inspector no.( e filnnllcicicspceuon rust
col proval slnllcberobtained fromllthc buildi cg
inspec(or when the reroofing is completed.
]. All types of roof shall be icispcctc(I pi for to any roof being installed.
q, In oder to receive a final, you must complete steps I, 2, and 7.
1,) 1'rcinspecliou or (car off approval.
2) In progress inspcclion approval.
7.) Final inspcclion approval.
Opoable smol(c(Icicclor vaificalio(
b.) Spark ,uccstor installation
5. If pl}'((ood is installed, a plywood nail Inspection is Ic(pnlc(l.
G, jr any roof is applied without fust obtaining an inspcclion, you will be required to remove all nov
material down to lice shc:dhing out a building iuspcctor (will inspect all sheathing at (hal time.
\v l'_ UNDLItS'fA1JD 'MIL ADOVF_ POLICYON REROOFING AND WILL COMPLY WICfII II LL
POLICY
IIOMLOWNLRS NAMI :
ADDRESS: '
REROOFING COMPANY NAME:
APPLICANI'S SIGNA'1'URIs:
CITY OF CUITR.I'INO
DUILDINO DEPAR'l MENT
s
Rcroorhvinword
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Citrj Of cwpe-1,0110
. .0 . r.o,ao.soil
loloo lam Annuli r - Cupci lino,CA 95015-0500
Ctip,tino,CA 95011-3255
f e.lepl,ne: 14001 2524505
fA%: (1011)252-0751
C:OMMUNI fY UEVf.LOI'M[Nr
SMOICI- Dl I_L'C'I OIC CER`111=ICA'I'E OlCOMPLIANCE
I understand and comply with Section 1210-a of the Uniform Building Code.
SCC11011 1210-a requires whcu repairs to a siugle family dwelling exceed $1,000, a smoke
detector will be installed, nuxurled on 1Ile cciliug or wall in each sleeping room and nt a
point centrally located in the corridor or arca giving access to room used for sleeping
purposes. If existing smoked detectors comply, no new detector shall be required.
I understand the above rcquiromenl and cellify (hill we now have suloke detectors
inslalled that do comply.
ADDRESS.
PERMITNUMn-,t:
IIOMI7.OWNfiRS SICNA'I'URE:
DA'Z'E:
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