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R-4543 APPLICATION FOR clry of cuPERrINo rNU BER R- 4543 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 180 DAYS FROM LASTCALLED INSPECTION. • / {�IQ�v� (i 1 RESIDENTIAL COMMERCIAL OTHER OWNER'S './ f HAZARDOUS FIRE AREA NAME �/�//'/✓ ` LJ� VES ❑ roolassembly staequifred, ClassA NO I Inifil I.C.B.O.# ADDRESS -jZ 3 s/'/ / ✓'� DA A44 IEXISTING ROOF COVERING PHONE 7 �— Sr��J NUMBER OF EXISTING COVERINGS 4- L� CONTRACTOR'S /7 1 NAME e Ifo D eq.,o TO BE REMOVED TO BE RETAINED ADDRESS s Z/ S l S/f N LOS c Cq TYPE OF ROOF COVERING CITY&ZIP EXISTING PHONE ,7 BUILT-UP ROOF ❑ CENSE NUMBER Z8 2 ASPHALT SHINGLES E]LICENSED CONTRACTORS DECLARATION hereby affirm that I em licensed under provisions of Chapter 9(commencing with SectionWOOD SHAKES 7000)of.Division 3 of me Business and Professions Code,and my license s and In lull force entl effect' WOOD SHINGLES ❑ License Class C 3 9 Lic.Numbe/r Date —( �� contractor / P (% /yQ� � OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em 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 lar such permit to lila a signed statement that he Is licensed pursuant to the provisions • of the Contractor's License Lew(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 fora permit subjects the applicant to e civil penalty of not more than five hundred dollars($500).): 01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for eels(Sec.7044,Business and Profes- sions Code: The Connector's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,and who does such work himself or through his own employees,provided that r such Improvements are not Intended or offered for sale.If,however,the building or Improvement s/ G is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑�`�'• ��/ not build or Improve for purpose of sale.). ❑I,as owner of the property,em exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PE MIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Pn Buildin as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this b`^ permit Is Issued. 11) ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Spa !6 0`0. Seismic the Labor Code,for the performance of the work for which this permit I$Issued.My Workers Total Compensation mews/� r��Tier and Policy number are: ^/rs Carrier 5��_• '••� �Uy,J Policy No. Y (JitCPERMI THORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' Cn COMPENSATION INSURANCE N.C.❑ YIJ (This section need nol be completed if the permit is for one hundred dollars 1$100)or less.) I 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 Cell- All roofs shall be inspected priollitoarry rootirig material being forma. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOT CE TO APPLICANT:subject t.the Workers'C mpensation proafterivisionis of then Lacate bor Code,you musof t fo thwlidthbecome comply Applicant understands and will comply with all non point with such provisions or this permit shelfbe deemed revokes. - Source regulations. I (certify thatall have react thisapplicationordinancenadstte laws wsebting t building constcorrect io ,and �� to comply with allafyand this aprtlationasd state tethat the relating information building construction,and All roof coverings to be class"C"or bett hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. /� we)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities, lLlAj>�� ' judgments,costs and expanses which they In any way accrue epelnal said City In consequence SIGNATURE OF APPLICANT DATE of the judgments, granting of thisand 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 SUBIECI': REROOFING POLICY FOR THE CI'lY OF CUPERTINO BUILDING DEPARTIIE`T PR10R TO ISSUANCE OF PERMIT AND INSPECTION PHASE. . 1. Prior to permit issuance, you "lust agree to comply with U.B.C. standards and manuf ctdrers spec's on reroofing. ' 2. New roor coverings shall not be applied tvitlnout first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall be obtained from the building inspector when (lie reroofing is completed. 3. All types or roorshall be inspected prior to any roorbeing installed. 4. In order to receive a final,you must complete steps 1,2, and 3. 1,) Preirspec-doll or tear of approval. 2.) In progress inspection approval. • 3.) Final inspection approval a.) Operable smoke detector vcrificntion b.) Spark arrestor i"stallatio" 5, if plywood is installed, a plywood nail inspcciiou is reluircd. G. If mry too[is applied without first obtaining nn inspe-_tie", You will be required to remove all "ev material down to lire shc.11riltg and a building inspector will inspe^_t all sheathing at that times WE UNDERS-FANO TILE ABOVE POLICY ON RE•i2COPING AND WILL COMPLY WITH TIlE POLICY / IIONLE-OWNERS NAV1E: ADDRESS: �73Sy /��nnGNr� � T REROOFING CONLpj%NY l,IANIE: DDe/C/ APPLICANTS SIGNATURE: • CI'IY OF CUPERTINO BUILDING DEPARTNLENT Rcroo[A%imrord i j Citi, of cuperli"O - SMOKE DETECTOR CERTIFICATE Or COMPLIANCE I understand and comply will, Section 1210-a of the Uniform Building Code. Section 1210-a requires when repairs to a single family dwelling exceed SI,000, a smoke detector will be installed, mounted on the ceiling or wall in each sleeping room and at a • point centrally located in the corridor or area giving access to room used' for sleeping purposes. If existing smoke detectors comply, no new detector shall be required. I understand the above requirement and certify (lint we,now have smoke detectors.: installed that do comply. ADDRESS: PERMIT NUMBER: yS�3 HOMEOWNERS SIGNATURE: C D A•rE: I winword/smkdet