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R-4665 PERMIT � APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4665 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 103 AJ-P Y4 PY RESIDENTIA COMMERCIAL OTHER OWNER'S y /yO HAZARDOUS FIRE AREA NAMES 0.✓ / // nderstand that a Class A VL YES ❑ Il yes-I uroot assembly is required ��1 ✓n� NO Initial I.C.B.O.If ADDRESS! 83.5 /L O✓P✓t�e[�' v/. EXISTING ROOF COVERING PHONE — NUMBER OF EXISTING COVERINGS / Z CONTRACTOR'S �f /� -r- NAME— /Y/Kf4il�ON �COF'TY t;4 J-vT G TO BE REMOVED P TO BE RETAINED ADDRESSf �1 /-7 I' TaI / y- TYPE OF ROOF COVERING CITY&ZIP--133 ! / 0.57 U-/b✓i 5 EXISTING �L10- 8 -`1 zZz PHONE 9 9 BUILT-UP ROOFLICENSE ❑ NUMBER Z Z "1 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect. WOOD SHINGLES � License Class r 7/Z-L 7 y/ Llc.Number n Data 1�� Z0/y-� Contractor �/��'4'�' �co F'r�(4 �i-LCt OTHER(SPECIFY) ❑ 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 Ilcansetl pursuant to the provisions . of the Contractor'.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 ]3d�t'a✓�j exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to / a civil penalty of not mora than five hundred dollars($500).): WOOD SHAKES E]1,as owner of the property,or my employees with wages as their sola compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sionsCode:The Contractora License Law does not apply to an owner of property who builds or WOODSHINGLES Improves thereon,and who does such work himself or th rough 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 contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I,C.B4O. 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 Contractor's License Law. PROVIDE MFGR, INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERUT FEE WORKER'S COMPENSATION DECLARATION ., I hereby aalrm under penalty of perjury one of the following declaration: ° L'7, 11 ❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, c Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this rile r-1 ��70%6[� permit is issued. /g O , SeISR11C �L I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Q the Labor Code,for the performance of the work for which this permit is Issued.My Worker's ,��Y `e fN l/ Total .the Insur nae ca[,r(Jler and Policy number are: Carrier S�.L'�-e r`KiiPolicy No, ILI7- 7` 0 5 PERMWAUTHORIZATION DATE CERTIFICATE O�XEMP FROM WORKERS' INSURANCE 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, -heli not employ any person In any manner so as to become subject to the Workers' ompensatlon Laws of CSY. All Ishall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date 1 f O f Apvllpant inspection,I agree to remove all new materials for inspection. subjectItoEtn Workers'Compensationprovafter tislonlsoBheLaborCode,rtificate of yolumustforthwlithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shalg,be deemed revoked. source regulations. I certify that I have road 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 coverm to be class"Wrter. hemby authorize representatives of this city to enter upon the above-mentionatl property for In- hereby purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, ludgmenis,costs and expenses which may in any way accrue against sold Or 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION' ` OFFICE COPY 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. 1,) 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 n HOMEOWNERS NAME: t o r �i 11L ADDRESS: l© 33 /lDdPvtL�PV !� REROOFING COMPANY NAME: a✓ V APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTMENT • Reroof/winword