R-3723 (2) PERMIT R_ 3723
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
180 DAYS FROM LAST CALLED INSPECTION.
- BUILDING ADDRESS ��030 0.��,2�8 Q� BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
p HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESSI-2gO3Cl ii.[!a _ZYyV2-, C21• EXISTING ROOF COVERING
PHONE 400 - 7 NUMBER OF EXISTING COVERINGS a-
CONTRACTOR'S
/� TO BE REMOVED � TO BE RETAINED
NAME d�K� .US (JdT/� -Z1�C' TYPE OF ROOF COVERING
ADDRESS
CITY Voll/ 9 EXISTING T�'G
81 21b /0,3&? .RP Ate,/
PHONE BUILT-UP ROOF
LICENSE 55y3.S� ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
1 Winer Section
7000 I of licensed under provisions or dChapter 9Prof..(cpm
cine y[] an Non 70001 of and affect 3 or the ensinne and P.olessiom Cotle, WOOD SHINGLES
me m.Cl as b rill .and erfaR. /
Licmu Clap Lic.Number
Dec. Contn<tor OTHER (SPECIFY)
OWNER BUILDER DECLARATIO
I hereby sIfirm that I am .pomp[ from In.C.n".ctoi.IL'cense Law for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
Or county which requires a permit t0 construct,alter, improve, d.moli•h,Or
rmait any n.p<br.,pilor to ns btpense, also requires the.ppHcani for m<n BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to Ina provisions
of Iia Contract3oo:a Blanes Lew Professions
s (commencing with Section t7000)
here
fromDivision 3 OI the Business and gedfa xem Coda)0r tb.1 he is exempt mem ASPHALT SHINGLES
from end the opsit for the perms exemption. Any violation of Section
7091.6 by any applicant bra permit subjects the applicant to a Civil penalty
Of 0071,as that rly. the property.
WOOD SHAKES
0 1,as owner of Ill•property,or my employees with wipes at Bair sole
compensation, will do the work,and the structure it nor intended or offered
for sale (Sec. 7004. Business and Professions Code: The Contractor's License WOOD SHINGLES
LOW does not apply to an owner of property who builds Or improves thereon,
and Who do.such work himself or through his own employees,provided that
such imptov.mentt ere not intended or offered for •.l.. If, however, the OTHER (SPECIFY)
building or improvement it 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.
0 1, . r of the property. + exclusively contracting with licensed
contractors 10 ...Itruct the project (sc. 7040, easiness and Professions
Ode. The Contractor's License Low does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds of improves thereon, and who contracts for such projects with e
contractor($)licensed pursuant to the Contractor's License Law.
C3su
am exempt under sac. ,e.6P.c. r this
reason APPLICATION DATE VALUATION PERMIT FEE
own., Data
WORKERS'COMPENSATION DECLARATIONp j BUlldl
I hereby affirm that 1 neve a certificate of consent to sel Linsur•,p K
JO
7ifiut.of Workers CompensationImus C.or a certified copy thereof(Sec. Seism
3800,L .1.
Policy o. 8L3.Company sew •'a
O.rlilietl copy a hereby
b sada ) ,�gg �U, Total
Certified copy is filed t 'lib on division. CI
Applican7
CERTIFIC P ON FROM ERs• N C 0 'B AUTHORIZATION DATE
COM E ATION INSURANCE
(This•action need not ompleted if the permit is for one hundred dol.
let.(f 1001 Or Ins.)
I cattily In.t in In. performance OI the work for which this permit
issued, I shall not employ any person in any manner so.s to become subject
to the Workers Compensation Laws of California.
Dab APPlic.nt
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption,
you should become subject to the Workers Compensation provisions of the
Labor Code,you mu. forthwith comply with such provisions or this permit All roofs shell be in9 Cted p[IpFtO any roofing materiel being
shall be deemed revoke.
I certify that I have read this application and sub that the above inform. Installed Lf ajl;�rKof Is.10 fled without first obtaining an
tion is correct. I .gree to comply with all city and county ordinances and
•fou laws relating to building construction, and hereby authorize represem Insp ee•t ova all new materialsforinapection
btives of this city to enter upon the above mentioned property for Inspection
Purposes.
we) agree to we. indemnify and keep harmless the City Of Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
.g.Inst said City in consequence of the granting of this Permit. SIGNATU E OF APPLICANT D E
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSPP, 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
C.
Cihq of Cl.Iiiel•lir'•o
• r.o.[lox 5uo ,
i Cu ,OM CA 05015050(1
10100 lone Avenue .
Cnpcilino,U 050115 )
'Ir.l r,p Lune: ('100) 2521,5505
IA%; I1011) 2520751
CpMN1UIdIIY VOVCIOPMCNT
SMOICI Df�I_Gc'I'Olf CI-ILTII_'C:M'L 0 COMI'I IA
I un(Icrsland PHd comply with Section 1210-a of the Uniform nuilding code.
Section 1210 a requires when repairs Io a single family dwelling exceed $1,000, a smoke l
detector will be installe(l, moulded on the ceiling or wall in each sleeping room and ala
point centrally located in the corridor or arca giving access to room used for sleeping
purposes. If existing smoked detectors comply, no new (Icleclor shall be require(l.
• ( wulerslan(I the above requirement and certify Thal we now have smoke detectors
. I . to corn 11 .
in:daaul llcnl c I y
ADDING%
090 Q a F)YiVp/ —
�C - 3
I'IsltMl'I" 1`IUNLI}ISR:
11OMI3OwNIsRS SIGNATURE: G [l
DM L:
winworcl/sAdcl
•
• SUUICCI'; 1(1;1(00[7 INC) POLICY I Olt '1'11E Cll'Y 01 CUI'EIl'I'lIJO BUILUIIJG llLI'AlllM1 Nl'
P](IOR,10 ISSUANCI.S Ol' I'I:Iffv1l I AND IIJSI'I;CI'1011 PlIASC..
1. Plior to pcmnt Isslallcc, you must agree to comply +villi U.B.C. slendarrls and ni,1nuB+clurcis spcc's
on rcroofiug.
Ili 11
I
2 1-101111-10111II cCIn New If building inspectors. A Iall illlspcelion Imit :111d gpprov.lg S11:111l be lull
obtained frollhc building
inspCCIOI +vhcn the tCloofwg Is conq+IClcd.
I All types of ux+f slmll be iti.sllccicd prior to any roof being insl:dled.
q, In order to Icccivc:1 [roar, you Illrlsl coogrlcic slcps I, 2, and J.
I,) 111cinspcction or Icm off opploval.
2.) In ptogtcss inspcclio❑ approval.
3. Pin,tl inspccliou app o
val.
,I ) Opctablc smoke detector vclificdion
• b ) Spark arlcslor IIISla Ai011 1.
5. Irplywood is inslAIC6, a plpWod nail iuspcclion is rcquilcd.
G, If :uly Ioof is :q+plicd without firs[ obtaining an inspccliou, you +vill be rcquilcd to MOM all nc+v
m:derinl down to [lie shuthing :Ind n building inspector +vill inspccl all sheathing al Ihnt little.
\Nli UNDERSTAND 1'111; AIJOVC I'OLICI' ON ItI;ItOOfING AND WILL COMPLY W1I11 '1'11L
POLICY
IIOMI;OWI`IL;IiS NAME:.
ADDIu;SS:
ItGIIOOI7ING COMPANY NAME: p
APPLICANI'S SIGNATURC:
CITY 017 CUPER'1'INO
IIUILDING DI;I'AICIML•N'f
IlctooA+vin+vold