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R-5666• • • OFFICE COPY s RR- 5666 APPLICATION FOR CITY OF CUPERTINO NU 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 C�Tr I r RESIDENTIAL COMMERCIAL OTHER OWNER HAZARDOUS FIRE AREA YES ❑ Ii as — I understand that a Class A NAME roof assembly is required. NO, ❑ Initial I.C.B.O. k ROOF COVERING ADDR(E(�S�'S�EXISTING NUMBER OF EXISTING COVERINGS 2 PHONE CONTRACTOR'S�' ^^ �/} ( z O TO BE REMOVED TO BE RETAINED _ r w I NAME O TYPE OF ROOF COVERING ADDREss!I CITY a ZIP' L EXISTING Q ( PHONE' I \C7� '\� BUILT-UP ROOF ❑ LICENSE NUMBER, ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provislons of Chapter 9 (commencing with Section WOOD SHAKES . • 7000)of Division 3 of the Business and Professions Code, and my license Is In lull force and 1 effect. i k4 I I— le Lic. Number WOOD SHINGLES ❑ Date Contracts✓'_ OTHER (SPECIFY) ❑ - OWNER.BUILDER DECLAR PROPOSED I hereby affirm that am exempt from the Contractor's License Law for the bllowing reason. 777 �� (Sec. 7031.5, Business and Professions Code: Any city or county which requires e 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 of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divlelon 3 of the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).1: WOOD SHAKES ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do ❑ the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes. cions Co de: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon, and who does such work himself or through his own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractor$ 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 bullds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑ 1 am exempt under Sec. ,B 8 P. C. for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑ I have and will maintain a Certificate 01 Consent to sell -Insure for Worker's Compensation, for by Section 3700 Labor Code, for for /� n Building as provided of the the performance of the work which this 1 permit Is Issued. - y 1 yV� ' 111 �� -Seismic ❑ I have and will maintain Worker's Compensation Insurance, as required by n 3700 0l the Labor Code, for the performance of the work or which t s permll la Issued. tl. MyMy Work r'9 Total Comp o Insure ce mePolicy numb are: � f ti C arder Po1lcyNo. I PERMIT AUTHORIZATION 9=1 01 DA E 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 less.) I certify that In the performance of the work for which this permit Is Issued, 1 shell not employ any person In any manner so as to become subject to the Workers' Compensation Laws of Cell. All ro s shall be inspected prior to any roofin m erial b ing lomIa inst ed. If a roof is installed without first obtaining an Date Applicant ! ` L� t A .�(�YY'� inspection, I agree to remove all new materials for inspection. NOTICE APPL ANT: 1f, after making this Certificate of Exemption, you should become A Ilcant understands and will comply with all non point pp P Y 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 I have read this application and state that the above Information Is Correct.I agree to and countyordinances and to construction, and All rOwerings to l) IaSS "C" or better. rcityep the entling hereby authorize reprasentativee of this city to anter upon iha ebovementlOnetl property for In. hereby authorize ter upon f ep (Wel (Wel agree to save, agree to and keep harmless the City of Cupertino against liabilities, expenses judgments, coats and expenses which may in any way accrue against said City In consequence of the granting of this permit. NATURE OF APPLICANT DTE 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: REROOFD;G POLICY FOR THE CITY OF CUPERTNO BUII.DNG DEPP'a'n IEN T PRIOR TO ISSUANCE OF PER.NG 1 A'� NSPEC1ION PHASE. 1. Prior to pe mit issuance, vau must a;ee to comply tvith U.B.C. s•,andards and manufacturers sec's an rc:cofing. 2. Ne•.v roof coverings shall not be aoolied without first obtaining all in -=cc -ion and written approval from the building inspet':or. A Gaal tnspecnon and approval shall be obtained Pram the building insrec:or when the re:cofing is completed. 3. All types of roof shall be inspected prior to any roof being installed_ 4. In order to receive a final, You mu --t campiete steps 1, 2, and 3. 1,) P:eir=ccaoa or tear off approval - 2.) In progess ir"-ec:ion approval. 3.) Final inspe:lon 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 tnsoe_.ion, you will be required to remove all new material down to the sherching and a building inspe"pr will in_ c,- all sheathing at that time. NVE UNDERSTADiD TEE ABOVE POLICY ON REROOFING POLICY EONfEOWNEM NAME: ADDRESS:. "' REROOFING COMPANY NAME: APPLICA,`+TS SIGNATURE: CIT( OF CUPERTINO BUILDCNG DEPARTMENT Re:ooflwinwdrd AND WILL CObEPLY WITIH Tr`= ltiAIMWWA�yi7hMI Wi W AMIE