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R-56630 P PERMIT R— 5663 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1 B DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS O isGIs 1 /' 1 RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA 1� l/��/ YES ❑ If - I understand ired.at Class NAME— r )� �" /lT roofassembly.requs NO Initial_ LC.B.O, a � :: EXISTING ROOF COVERING ADDRES NUMBER OF EXISTING COVERINGS , PHONE �r CONT CTOR'S BE REMOVED � TO BE RETAINED ITO NAMADDRESS f ntjg � �-(-+ TYPE OF ROOF COVERING CITYsZIP I r `� w EXISTING q Is --(v\�J � -ROOF PHONE `�"�� BUILT -UP ❑ 11 � �'i NICENSE UMBER ASPHALTSHINGLES ❑ WOOD SHAKES , LICENS d under CONTRACTORS DECLARATION I hereby that em licensed under of Chapter 9 (commencing with Section fessprovisions 7000) of Division 3 of Ih Business antl Prolesaio sCotla ntl my license is In full force and slon effect. WOOD SHINGLES ❑ 3O� License Cles LIC. Numb ' OTHER (SPECIFY) ❑ Dme4- � contracto ' of NER-BUILDER DECLARATION ROPOSED 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, after, Improve, demolish, or repair any structure. prior to its issuance, also requires the BUILT-UP ROOF A fp❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractors License Law (Chapter g (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 SHINGlli r exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to I e civil penalty of not more than five hundred dollars ($500).):/� ❑1, as owner of the property, or my employees with wages as their sole compensation, wl11 do WOOD SHAK9d}'U♦ GVPIr the work, and the structure is not Intended or offered for sale (Sec. 7040, Business and Proles- stone Code: The Contractor's License Law does not apply to an owner of property who builds or l j+ WOOD SHINGLES NQ Improves thereon, and who does such work himself or through his own employees, provided that such Improvements are not Intended or offered for eels. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). 01, as owner of the property, em 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 contractors) licensed pursuant to the Contractors License Law. MFGR. INSTALLATION SPECS. 01 am exempt under Sec. ,B 8 P. C. lot this reason .PROVIDE Owner Date APPLICATION DATE VALUATION PERMIT FE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: 01 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code, for the performance of the work tar which this permit is issued. 01 have and will maintain Worker's Compensation Insurance, as required by Section 370001 1' 1 /L Ir,'.ylr/ 1(4 1l/ Qr/I 0� Seismic the _the Labor Code, for he performance of the work for hich this permit Is Issued. My Worker's Total Com I o I r oc anter a Iicy number e �^ I' I fZ ( l/�`J% PERMIT AUTHORIZATION TE Carr Policy No. CERTIFICATE OF EXEMPTION F OM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed If the permit is for one hundred dollars ($100) or less.) If if I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person any mannq so as to become subject to the Workers' Compensation a of C u- All roofs shali inspected prior to any roofing material being 1orn1 '( /� ((,(�-Installed. If a roof is installed without first obtainingan Date � � �' - Irr>;pection, I agree to remove all new materials for inspection. 4`'1'Adpncant NOTICE APPLICAN If, alter making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply Applicant understands and will comply with all non Dint pP P Y P with such provisions or this permit shaipbe deemed revoked. source regulations. I certify that I have read this application and state that the above information is correctI 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. I hereby authorize representatives of this city to Doter upon the above-mentioned property for in. hereby purposes. ��` � (We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, 1 1 l P judgmerim, costs and expenses which may in any way accrue against said City Inconsequence SIGNATURE OF APPLICANT DA �� 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 0 SUBJECT: REROOFING POLICY FOR TIT- CIT'f OF CUPERTNO BUR.DL`tG DEPART` IEN i PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you mus, agree to comply with U.B.C. s andards and m ufacm ea sec's on reroofing. 2. New roof coverings shall not be applied w thour first abmining all in_-ecticn and writ`,= approval from the building inector. A final irtscection and approval shall be obtained -From the building sp inspector when the reroofing is camoteted. 3. All types of roof shall be inspected prior to any roof being ins -ailed. 4. In order to receive a final, you must complete steps 1, 2, and 3. 1,) P,, -;=c -tion or tear off approval. 2,) In progress inspection approval. 3.) Final insperioa approval. a.) Operable smoke detector veriucation . b.) Spark arrestor installation 5.. If plywood is installed, a plywood nail inspec;ica is required. 6. If any roof is applied without firs obtaining an inspection, you will be required to remove all new material down to the sheathing and a butldutg inspe= or will inspect all sheathing at that time. 0 WE UNDERSTAND TIIE ABOVE POLICY ON REROOFING P*1D WII L COMPLY V= -Tr' POLICY HONIZON.+ERS I ADDRESS; `. - REROOFING Ct APPLICA,`7S S___.-__ _- CITY OF CUPERTNO BUILDING DEPARTvIENT Rerooflwimvord