R-3922 PERMIT R_ 3922
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 ADDRESS /,1 /J / BUILDING USE
/02-7/ GU�$rq-Co� D!1 _ RESIDENTIAL v COMMERCIAL OTHER
OWNER'S
ROOF
NAME • kiuv FIREARDOUS /l�, O COVERING
mm AREA CLASS
�OZ
ADDRESS 7l LLI�STAG,eES X/� EXISTING ROOF COVERING PHONE 2:5-2 _ L�
• —G-7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/ TO BE REMOVED TO BE RETAINED
NAME 4N0 KC�OF �../cl TYPE OF OF`COVERING
ADDRESS
CITY&ZIP 7� D�' ��� EXISTING
PHONE `�—`�� ZCo�-Zoz.s- BUIL P ROOF
LICENSE Z,Sr� PHALT HI S
NUMBER �r WOOD SHA
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,I am licensed nd.r provisions of Chapter 9 Ic`xhi
ling with Section ]0001 f Division 3 of the Business and Professions Cod.. WOODS LES
and my I is in uu�o and eff«L /I I` /
License Cbe C.mA mbar L. J kY OT PECIFYY\
Data Contrxror
NE RBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for P OPOSE
the following reason. (Sec. 7031.5, Business and Profession$Code: Any city A I I]
Or County which requires a permit t0 COntI t,alt , improve, c amOlitn,Or
repair any structure.Prior tom imuenca,also raqu'a Ms applicant for such g I LT-UP RO
Permit to file a signed statement thea he is license pursuant to the provisions 91995 .
of the Contractor's License Lew (Chapter g Ices encing with Section 7000) FEB
of Division 3 of the Business and Proration.C star or root he i.exempt[hare. ASP LT SHING
from end the basis for the alleged exampC Any viobti.. of Section
7031.5 by any applicant for a perm;[Wbja s the epplicon[[O a civil penalty /•
A not mar.that Nva hundred dollar.(s50 .I: WOOD S CIIY 'r t.L��N4ifiU
I,as owner of the property, or m employees with wept$as their able
compensation,will do me work. end t arumure is not intended or offered yy00D SHINGLES
for Bele (Sac. 1044, Bv..nasa end Pro m Code: The Contractor'.License
Lew doe not apply [O a wrier ii raperty who build%or improves thereon,
and who dna such work himself. th,..gh his own employee.,provided that
wen imp.oy.mant. .r. not mt tied or
offered for sal.. If. however, the OTHER (SPECIFY) a
building a improvement i as within one year or c mpletion, the owner
Duildar will have he burden proving[ata he did not build or improve for
purpose of sale.) PROVIDE I.C.B.O. REPORT NO.
0 I, a owner of the roperty, am ..elusively connecting with licensed
camrectore to construct a project (Sec. 7044, Business and Professions
ode: TneContractor'sLucenseLawdoesnotapplytoanownerofproperty PROVIDE MFGR. INSTALLATION SPECS.
wno builds or improves thereon and who contracts for such projects with
conerxtorl.I licensed pursuant to the Contractor•License Lew.
soI am a=amp[ and.. sac. ,e.aP.c.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Building Or 0
hereby affirm that I nava
In ane consent to$coinsure,
d or
tfic. of.Workers'Compensation Insurance,aI .Unatl copy thereof(Sac. J/1
05 Seismic
3800Lab. tA/ tI
a4 �
Policy No. 7� P1Ti
8 Certified copy i$hereby mrni.n.e. Total C/
Cartif(� PY it filad.wiN thi city mspeMPW
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
(This$action need net be come,etatl ll 1 a p Tit it for no hundred 001
Ian.IS1001 OrIat.)
I Certify that in the performance of the ork for Which this permit it
issued, I shall not employ any parson in a manner to as to become subject7
to the Worker;Compensation Law.of C rine.
Dab Applicant
NOTICE TO APPLICANT: If, eh mhing this Cwtiflcate of Exemption,
you mould became subject to [ orkari Compensation Provisions of the
Labor Coati, you must formes comply with such provisions or this permit All roofsshall be Inspected prior to any roofing material being
.hall ba deem ad revoked.
I certify met 1 new. d this application and sou met the above Inform.. installed. If a roof Is Installed without first obtaining an
tion 1. torn$, I .gr to comply with .n pity and ....1, ordinaries.and action,I agree to remove�ll new materials for inspection.
sbb laws relating building construction, and hereby author is bpresem
t.tiva of this city o anur upon the.boy.m.ntioned property for into«non
Iw.I agree to Live, indamnily and keep harmless the City of Cupertino
against liabilities,judgments,cost.and expense.which may in any way accrue
against said City in conbeuonce of the granting of this permit. $IG NA RE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:-
INSP.
N-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
SUB1ECl': REROOFING POLICY FOR ' TIE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PEIUvUT AND 1NSPECI'ION PHASE.
1. Prior to penult issuance, you must agree to comply with, U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings slmll not be applied without first obtaining all inspection and wriflen approval
from the building inspector. A final inspecliou 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,) Preinspectiou or tear off approval.
2.) lit progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke defector verification
b.) Spark arrestor installation
S. If plywood is installed,a plywood nail inspection is required. r
G. If ally 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 lime.
WE UNDERS'T'AND TME ABOVE POLICY ON REROOFING AND WILL COMPLY WITH T11E
POLICY
IIOML•OWNERS NAME:
ADDRESS: 10 ZZ 1 A, 6r-ICE!Z Drl.
REROOFING COMPANY NAME: .{ F
APPLICANTS SIGNATURE:
f� v
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroollwimvord
I
I
Cites of CNpei-ti»o
I
SMOKE DETECTOR CER'FIFICATE 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.
ADDRESS: WESCfK21= S D2,
PERMfI'NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
I
winword/smkdel