R-4545 PERMIT
APPLICATION.FOR CITY OF CUPERTINO NUMBER R- 45 4 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
_ 100 DAYS FROM LAST CALLED INSPECTION.
.BUILDING ADDRESS
me Nib• if ( `RESIDENTIALJZ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
T /� /M1/ YES [3If yes—I understand that a Class A
NAME / O/41 OL LIZ_ ; Al S roof assembly is required.
NO ❑ Initial LC.B.O.M
ADDRESS -212 � 144-1/D/f//,� �T_ EXISTING ROOF COVERING
PHONE
-:7,47-7— ` �f7 NUMBER OF EXISTING COVERINGS '40-2t/67
G`
CONTRACTOR'S TO BE REMOVED—RS—TO BE RETAINED
NAME—
ADDRESS
AME ADDRESS �j (j �J �` ,,/,/ /_`'=A /� TYPE OF ROOF COVERING
CITY&ZIP b ( S L / i 5WA ff KG�t T 5;-/
9y/� EXISTING
PHONE �/ /� �iS BUILT-UP ROOF ❑
LICENSE �7
NUMBER- ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' WOOD SHINGLES ❑
License Cie. Lic.Number C
Data Contractor !Lf OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve.demolish,orrepalr any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES g��'LASS
❑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 Phi
sionsCode: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 WOOD SHINGLES E]such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-balder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
I,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 project.
with a contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 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:
r7p I
I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, py' � -aV Building G- A
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit haveissued. Seisr[tl ��(1( G
❑I have and will maintain Worker's Compensation Insurance,as required by Section Workers
A r
the Labor Cotle,for the performance of the work for which this permit Is issued.My Workefe
Compensetlon I��n/Js�f90ce carder ane Policy number are: Total
Carrier's �C �UW 1"2 Policy No. PERMIT AUTHORIZATION vl DATE' ' `"r V(
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit Is for one hundred dollars($100)or lass.) I7 /f
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 Cali- All roes shall be inspected prioelo any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE
TO after
anmaking
aoveylyou should became
subject 1the Worrkers'Cmpeneriioof the of
mst forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelfbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with ell city and county ordinances and stale laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
spection purposes. Q L/••�
(We)agree to say.,indemnity and keep harmless the City of Cupertino against Ileoililles, Li'!/ 's ��O l
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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
SUBIEC'I': REROOFING POLICY FOR 'I'i1L Ci-lY OF CUPERTINO BUILDING DEPART?dENT
PRIOR TO ISSUANCE OF PEp.NLIT AND INSPECTION PHASE.
L Prior to permit issunuce, you nnust agree to comply with U.B.C. standards and manuf cture:s spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining 311 inspection and written approval
from the building inspector. A final iuspcction and approval shall be obtained from [lie building
inspector when lire reroofing is completed.
3. All types of roof shall be inspected prior to any roaf being installed.
d. In order to receive a final,you must complete steps 1,2, and 3.
1,) Preitspeclioir or tear off approval.
2.) In progress inspection approval.
• 3.) Final inspection approval.
a.) Operable smoke detcclor verification
b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection 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 shcalhing and a building inspector will inspect all sheathing at that tiuta
WE UNDERSTAND TILr A13OVE POLICY ON ItEIIOOFING AND WILL COtv1PLY W1TI1 TILE
POLICY
HOMEOWNERS NAN E:
ADESS: a/t14 c
DR
REROOFING CO1b1PANY NAIv1E: —( l' /I04�/ �✓
APPLICANTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
Rcroofhvinword
Citi, of Ca4perti"o
iv II
SMOKE DETECTOR CERTIPICATE OF COMPLIANCE
I understand and comply will, Section 1210-a or the Uniform Building Code.
Section 1210-a requires when repairs to a single fau,iiy dwelling exceed 31,000, 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 use, I for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
I understand tl,e above requirement and certify (fiat we now have smoke detectors
installed that do comply.
ADDRESS: oZ2 Y3 `/ 914 wt A,),4 e T
PERNUT NUMBER: /-5
M
HOEOWNERS SIGNATURE: ---� •'PN '
DATE: ,
wiuword/smkdet