R-4654i]
OFFICE COPY
PERMIT 4654
APPLICATION FOR CITY OF CUPERTINO�.NILIMBERR-
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
, ('/J•
J((j`
Q i•I�..S
RESIDENTIAI COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes — I Understand that a Class A
NAMEroof
assembly is required.
NO Initial I.C.B.O. q
V
EXISTING ROOF COVERING
•
ADDRESS --41 f
ST — 3,31C,
NUMBER OF EXISTING COVERINGS eN jIq e
PHONE
TO BE REMOVED X TO BE RETAINED
CONTRACT 'S I ly C
NAME .J�1L.J
TYPE OF ROOF COVERING
ADDRESS_ / n
CITY a ZIP % 5—y /
aH ]� / • & a
EXISTING
ICAC p/�
/m
PHONE Ong �G �b / /
6
BUILT-UP ROOF ❑
LICENSE?
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES �J
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
affect. 2� 91 o6'
SHINGLES ID
License Class Lic. Number
/D _ 3o -9s'
OTHER SPECIFY
( )
Date Contractor-
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the lollowing reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, aper, Improve, demolish, or repair any structure, prior to its Issuance, also requires the
BUILT-UP ROOF Cl
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter B (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
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHINGLES
PA
a civil penalty of not more than five hundred dollars ($500).):
do
B
WOOD SHAKES ❑
❑ 1, as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
®�
sions Code: The Cantrector's License Lew does not apply to an owner of property who builds or
his that
WOOD SHINGLES
improves thereon, andwho does such work himself or through own employees, provided
such Improvements ere not intended or offered for sale. If, however, the building or Improvement
is the have the burden that he did
0000 TEZ.n
sold within one year of completion, owner -builder will of proving
OTHER (SPECIFY) (VI
t
not build or Improve for purpose of sale.).
nsv
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 projects
with a contrectogs) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. .B 8 P. C. for this reason
Owner Dale
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
r
I hereby affirm under penalty of perjury one of the following declaration:
[31 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
BUlldm
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is issued.
Seismic
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit is issued. My Worker's
Compensation In ur ce carne nd Icy number are:
A./"r1
Total
1x7 C q p/ 7� Zr�O
J' I b y
CEJ
PERMIT AUTHORI ION
DATE
Carrier Policy No.
CERTIFICAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
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 roofs shall be inspected prior to any roofing mattrial Ming
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 APPLICANT: If, alter making this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
Source regulations.
. I certify that; have read this application and state that the above information Is correct ) agree
to comply with all city and county ordinances and state laws relating to building construction, and
All ro f coven gs to be class "C" or better.
hereby authorize representatives o1 this city to anter upon the above-mentioned property for In-
hereby
purposes.
L !`
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
0
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection 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.
I,) Preinspection 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 nail inspection is required.
6. If any 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 time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY (//l y'
HOMEOWNERS NAME: rIXOC k
ADDRESS:
REROOFING COMPANY NAME: /� n
APPLICANT'S SIGNATURE: [
00
CITY OF CUPERTINO
BUILDING DEPARTMENT
Reroof/winword
u
Cupertino
C�
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 smoke detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
winvord/smkde[
Ika.s %r`L.S�tre.
R- 4G5 -ti
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Printed un Recycletl RIOT