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R-4583 APPLICATION FOR CITY OF CUPERTINO NUMBPERR R- 45 8 3 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT X (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 4 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS OP, S Lo RESIDENTIAL COMMERCIAL OTHER- I.Q OWNER'S HAZARDOUS FIRE AREA �/� q 7 ,/ r '- / /— �,//� YES ❑ If yes—I understand that a Class A NAME /"f /T T/ l/y 64 !� //'�r u/La(-CHIP roof essembty is required. / NO Initial I.C.B.O.K ADDRESS /I5 � //��iLfigna T2£1P 4-L EXISTING ROOF COVERING PHONE V NUMBER OF EXISTING COVERINGS CONTRACTOR'S �/Jt ,,[ NAME A 7-Z (root- r/— TO BE REMOVED TO BE RETAINED ADDRESS 14PE OFR OF rOVERING CITY a ZIP-.442 5-) 41 ef;IlYi ce�z(o fie& Zi EXISTING PHONE «�' S - �`�� �� BUILT-UP ROOF ❑ LICENSE NUMBER 6tj PL li-49 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION ` 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES �I`Pr'• 7000)of Division 3 of the Business and Professions Cotle,and my license Is In lull force and effect. WOOD SHINGLES License Class Uc.Number DOTHER(SPECIFY) Date contractor ❑ 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 previsions . of the Contractors License Law(Chapter 9(commencing with Section 70001 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 e civil1penalty of not more than five y employees dollars with wage WOOD SHAKES 11,as owner of the property,or teemployeeswith wages as their sole compensation,sand will do the work,and the structure 19 not intentletl or offered for sale(Sac.1044,Business and Profas- saons Code:The Contractor's License Law tloes not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,and who does such work himself or through has own employees,provided that such improvements are not Intended or offered for sale.It,however,the building or improvement is fold 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.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. I self PROVIDE'MFGR.INSTALLATION SPECS. 711 em exempt under Sec. ,B It P.C.for this reason 9 _ Owner Date APPLI DATE VALUATION r PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration fir/' I_ .., -11 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, �,G/- J9 Building G/013 as provided for by Section 3100 o1 the Labor Code,for the performance of the work for which this \f.0 �.`. permit Is issues. ~�h Seismic 7-0 ❑I have and will maintain Workers Compensation which this as required by Section 3700 of //N the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 11 'Compensation Insurance carrier and Policy number are: U Total Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (TMs section need not be completed It the permit Is for one hundred dollars($100)of lase.) 1\ I certify that In the performance aline work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Lowe of Cell. All roi shall be inspected prior to any roofing material being fornia, installed. It a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. eomeAPPLICANT: fposnthis Exemption, ausushould become subject rrs'Compensation rvfo of the Labor Code,you must forthwith Applicant understands and will comply with all non point with such provisions or this permit shelCbe deemed revoked. Source regulations. I certify that I 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 coverings o be class"C"or better. hereby authorize representatives o1 this city to enter upon the above-mentioned property for In. spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, • judgments,casts and expenses which may In any way accrue against said City an consequence -SIGNATURE OF APPLICANT DATE of the granting of this permit. PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. -GATE- 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. t 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 nn/�� HOMEOWNERS NAME: X9 �7/'��' t ADDRESS: A9 S >� �/G� � 7—/IPP �.rn �S/�5 REROOFING COMPANYNAME: APPLICANT'S'SIGNATURE: Q CITY OF CUPERTINO BUILDING DEPARTMENT • Reroof/winword. .