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R-5677 APPLICATION FOR CITY OF CUPERTINO NPERMIT UMBER R— 1J 677 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED -.^ WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS 10117 /}Olr'Q^n�c. � i� / !-F" RESIDENTIAL COMMERCIAL OTHER OWRER'S t� HAZARDOUS FIRE AREA j� T LLw W 0.M YES ❑ If yes-I understand that a Class A NAMELZY P n � 'JQ� L! d d ip Y 5. roof assembly is required. r NO Initial I.C.B.O.H ADDRESS/I`D 1 171 4 ri a-ma A- l-re- EXISTING ROOFCOVERING Y L1' 7 art ~D �i-/-� NUMBER OF EXISTING COVERINGR PHONE /A, 2"'{J 2 S S-(/_� r CONTRACVOFI'S' • rte°"'-� /` NAME ITO Y Y l 6G. /L 0 O F 1 ✓r G TO BE REMOVED TO BE RETAINED ADDRESS J (TYPE OF ROOF COVERING cITYBLP-3r-j//� /�f FLoarPr,,- r S EXISTING 9ec/w0 oGt' 00' r ' Cs-(?,V0 3 PHONE J` �� ^ BUILT-UP ROOF LICENSE NUMBER (.G 1 95 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION j hereby ision that em licensed under provisions of Chapter y(commencing with Section nd WOOD SHAKES ❑affirm 7000)of Division 3 of the Business and Professions Code,and rrry license is In full lone and effect. 2 `/ Q WOOD SHINGLES / License Class Us.Number_e•+ Date Contractor rilrrt rap0 OTHER(SPECIFY) ❑ 1� 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,or repair 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 J 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.4 IP exemption Any violation of Section 7 031.5 by any applicant for a Permit subject.the applicant to e civil penalty of not more than five hundred dollars($501 jtj� ❑1,as owner of the property WOOD SHAK ,or my employees with wages as their sole compensation,will do ER11 10 ���❑ the work,and the structure is not Intended or offered for sale(Sec 7044,Business and Profes. (��� sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SI'7NVbf EG ❑ improves thereon,and who does such work himself or through his own employees,provided that -�7r Luf,•L such Improvements are not Intended or offered for sale.If,however,the building or Improvement E h' is sold within one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) HC1ry� ❑ 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 contacts for such projects with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec ,B 8 P C.for this reason Own- Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, /� Q� Building as provided for by Section 3700 of the labor Code,for the performance of the work for which this /0 y 7 ? L permit is Issued. ( r J I Seismic I have and will maintain Workers 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 Total 'Compensation Insurance carrier and Policy number are. 0080 Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.0 ^ q (This section need not be completed it the permit is for one hundred a0nare( o) lass) / V I certify that In the performance of the work for which this permit is Issued I shall not employ v any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All rOOf s all be inspected prior to any ro ing m erial being fornia:.'7-,_vQ� installed. If a roof is installed without first obtaining an Date's L Applicant /` r r a rrea c_.•„'.-. inspection,I agree to remove all new materials for inspection. No6TICE TO APPLICANT: If,after making this Certificate of Exemption,you should becOlt�i i Applicant understands and will comply with all non subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y point with such provisions or this permit shalebe deemed revoked source regulations. I certify that I have read this application and elate that the above Information Is correct.I agree to comply with all city and county ordinances and state 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 urposes. (We) �,,/� /•� m ` �Q 7 (We)agree to save,indemnify and keep harmless the City of Cupertino egelnsl Ileblhues. _/-�Q rl'J C� ' 4�vvl �i 4 Cf-•� T]' judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT -011 DATE I of the granting of this permit. rRE-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 - — SUBJECT: REROOFING POLICY FOR THE C1TY '0F CUPERTINO BUILDM DEPPIaT IEINT PRIOR TO ISSUANCE OF PERMIT AND I`1SPECTION nvAcE 1. Prior to permit issu=ce, you must a,e-_ to comply with U.B.C. standards and manufaca:rers sr_'s on reroofing. 2. New roof coverings'stibll nor be'aop lied,wi[heut firzt obtaining all inspection and wrinen approval from the building inspecror. A 5im1' i*715e=:ion and approval shall be obtained from the buildin_2 inspector when the reroofing is completed. 3. All types of roof shall be inspected prior to any roof being installed. 4. In order to rr_eive a Rul;'you mu_a'complece steps 1,2, and 3. 1,) Preinnr_tion or test off approval. 2.) In pro;ess in_spe7--h spprovaI. 3.) Final inspection approval. a.) Operable smoke de—:or ve..ifiption ' b.) „Spark arestor installation 5. If plywood is installed,a.plywood nail inspe•_'don is required. 6. If any reef is applied.without firs obtaining an inspection you will be required to remove all new material down to the.;h=ddng and a building inspe^_:or will in_spec,all sheathing at that time. NVE UNDERSTAND TI-.r ABOVE POLICY ON REROOFING AND WILL COiVJpLY WITri TriE POLICY HOMEOWNEIRS NAME: P; Y P Kl • 0.v 01 kA-.t-0-1 d QJ ,Ie - S ADDRESS? /f� // 1T,� r� �i �ci {u e l U/7P ��c"D REROOFING. COIv,1PANY N.N[E. Q ' '�qO— APPLICANTS SIGNATiTRE:: t C 9, -cec7 f3 a CITY.OF CUPERTINO. BUILDING DEPARTMENT Rerocf/winword .