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R-4532 PERMIT R_ 4 5 3 2:�] APPLICATION FOR CITY of CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED • WITHIN DAYS PERMIT ISSUANCE OR WI DAYSS FROM LAST CALLED INSPECTION. l BUILDING ADDRESS �r-�p p I� a I�DQJ PT VC�V I ✓� RESIDENTIAL COMMERCIAL OTHER - OWNERS \/p HAZARDOUS FIRE AREA NAME Lew f,\I1h�CU u1�e•,J/nt, S+r�..hLa,.�� NO a roof assembly sfarequuend duaClass A I.C.B.O.A ADDRESs �� l� I , V� • , I 11�D EXISTING ROOF COVERING PHONErl�)Q) _ 3(a NUMBER OF EXISTING COVERINGS CONTRACT`/1n NAME.1� �' / 1 M l AN`JLC ,SAA I�V WI r.Ja'11:..• TO BE REMOVED TO BE RETAINED ADDRESS x-�(7� y---•��{'''��-��y� ((��s�� TYPE OF ROOF COVERING CITYBZIPInQe P ^ ld/LOaLeA 0 q1,--y14 •�(�� -�` ,/ / EXISTING PHONE O' '�U"'!`'"I BUILT-UP ROOF ❑ LICENSE II II NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. I�7 — WOOD SHINGLES ❑ License Clear Lic.Number Det. I Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DE PROPOSED I hereby affirm that I am exempt from the Contract Licen w for the following reason. (Sec.7031.5,Business and Professions Code: Any city or co 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 - • 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 of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protes- sloes Code: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 Intentletl or offered for sale.If,however,the bulltling or Improvement Is sold within one year of completion,the owneobutltler 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 projects with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 em exempt under Sec. ,B It 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: a ` ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, ^/'� BUIIdii s as provided for by Section 3700 of the Labor Code.for the performance Of the work for which this W P?r I Is issued. OCT 24 1 - jlD�• seiBmiD have and will themaintain Worker's Compensation Insurance,ae required by Section 3700 of thLabor Code,for the performance of the work for which this permit Is Issued.My Worker's Total CIp nsurence terrier end Policy number are: 4•il. i - Carrier }/_ CERTIFICATE FROM MW PERMIT�AUTHORIZATION DATE CERTIFICATE EN EXEMPTION FROM WORKERS' COMPENSATION the ON INSURANCE N.C. (This section need not be completes If the permit Is for one hundred tlollars($100)or IessJ 1 certify that In the performance of the work for which this permit Is Issued,I shell not employ any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be insifected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remo a all new materials for inspection. NOTICE TO APPLICANT: It after making this Certificate Of Exemption,you should become Applicant understan a will comply with all non subject Io the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y point with such provisions or this permit shall be deemed revoked. source regulation I certify that 1 have read this application and state 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 cover' C "C"or better. hereby authorize representatives of this city to enter upon the above-mentloned property for In- spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, Ip ,5 • judgments,costs and expenses which may In any way accrue against said City In consequence SI OF APPLICANT DA E 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 - _ SUB1ECl': REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTME:Ff PRIOR TO 1SSUACICE OF PEP-NUT AND INSPECTION PHASE. 1. Prior to permit issuance, you must agree to caarply with U.B.C. standards and nranuf crurers specs Oil reroofing. ' 2. New roof coverings shall not be applied tivilhoul first obtaining all inspection and written approval from the building iuspcclor. A final inspccliou and approval shall be obtained from the building inspector when lire rcreofrng is complcled. 3. All types of roorshall be inspected prior to any reorbciug installed. d. In order to receive a final,you Must complete steps 1,2, and 3. 1,) Preinspcclioir or tear off approval. 2.) In progress inspcction approval. • 3.) Final inspection approval. aJ Operable smoke deleclor vcrificaliou b.) Spark arrestor installation 5. If plywood is iuslallcd, a plywood nail inspection is rcquircd. G. If any,roof is applied without first obtaining an inspection, you will be rcquircd to milove all nes material dawn to Ilre sheathing and a building inspector will iuspe^_t all sIl=tlrirlg at that time. WE UNDERSFAND 'FI 1L• A170VE POLICY ON RERCOFING AND WILL COMPLY WITH TIIE POLICY IlOtviLOWNEi?S NAME: Q J ADDRESS: 1 6 . (I-& REROOFING CONiPANY HANE: 1 APPLICANTS SIGNATURE: ' • CiIY OF CUPERTINO BUILDING DEPARTNLIHN ' Rmof/Mnword