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R-5530 APPLICATION FOR CITY OF CUPERTINO NUMBER PERMIT R- 5530 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 1BO DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS © RESIDENTIAL__— COMMERCIAL OTHER— OWNERS THERO ERS HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAME roof assembly is required NO initial_ I.C.B.O.# ADDRESS (j��- ` ,2—I/ EXISTING ROOF COVERING PHONE J� NUMBER OF EXISTING COVERINGS CONTRACTOR'S f TO BE REMOVED TO BE RETAINED NAME— ADDRESSe �., TYPE OF ROOF COVERING CITY 8 ZIP ,Gc, t ` EXISTING • PHONE BUILT-UP ROOFLICENSE ❑ NUMBER S J 7 3 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencingwith Secllon QQ SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. S 7^TW OD SHINGLES ❑ License Class US,Number Date Contractor77� OTHER(SPECIFY) ❑ WNER-BUILDER DECLARAT PROPOSED I hereby affirm that I am exempt from the Contractor's Li se Lew 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 fila a signed statement that he Is licensed pursuant to the provisions • of the Contractors 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 ❑ �( (l exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to pp R ` a civil penalty of not more than five hundred dollars($500).): P 4'Y +� C]1,as owner of the propWOOD SHAKES property,or my employees with wages as their sole compensation,will do 1 the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGIVGi� ❑ Improves thereon,and who does such work himself or through his own employees,provided that 5 G' such improvements are not Intended or offered for sale.It,however,the building or improvement rJ 30 A Is said within one year of completion,the owner-builder will have the burden of proving that no did OTHER (SYNP.)FY)\L 6 not build or Improve for purpose of sale.). OF LUY� ❑1,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 Law doss not PROVIDE I.C.B.O.REPO �rvYY/ 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 $PEO$, ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT 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 Worker's Compensation, BUlldln as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. C/ ❑I have and will in main Workor'a Compensation Insurance,as required by Section 3700 of ''7J00 , 0.0 S the Labor Cod ,for Ise pe mance of the work for which this permit is Issued.My Worker's UUU Compensatl In nce filer an 011pynumberere: Tota v Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EX PTION FROM WORKERS' COMPENSATI N INSURANCE N.C.] (This section need not be completed If the permit Is for one hundred dollars($100)or less.) 1 certify that in the performance of the work for which this permit is Issued,I shall not employ any person In any manner so as to became subject to the Workers Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you Should become A lIC understands and will Comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P with such provisions or this permit shall be deemed revoked. sour e r UIations. 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 A roof ve ' tis to be Cl "C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. sppurposes. (We) r (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, U J 10d9ments.costa and expenses which may in any way accrue against said City In consequence of the granting of this permit. ATU PLICANT DATE 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: RE_ROOFLNG POLICY FOR TrE CITY OF CUPERT 10 RUILDNR71 G DEPA ,�V i PRiORTOISSU+`ICEOFPER:,IITANDI`+'SPECTIONP ASE. 1. Prior to permit issuance, veu mus ag.ee to comeiv with U.B.C. sand::ds and ranuf:c. :ers spec's on reroofing. 2. New roof coverings shall not be applied without first obtaining all inspection and wrr= acerovai from the building inse!_:or. A anal inspection and approval shall be obtained from the building inmector when the reroofing is completed. 3. All types of roof shall be ins-pe=-ed prior to any roof being installed. 4. In order to receive a final,You =n:ample:e steps I, 2, and 3. in 1,) P:ei=ecdon or to off apprcv-J. 2.) In pro;ess inspection auprc%-J- 3.) Final inspection approval. a.) Ore.-able snok.-detector verificadon • b.) Sparc arrestor in_ralad°n 5. If plywacd is installed,a plywood nail ince=don is require•'_ 6fist obtaining an inspeo0. You will be required to remove all new . If any roof is applied without material down to the sheathing and a buildin;ince or will in�r all sheathing at that time. WE UNDERSTAND THE ABOVE POLICY ON REROOFING P_ND WILL COMPLY WITH TEE POLICY EOiv1EO\WERS NAME: j cool/ P�DRESS REROOFING COIv1PANYNAVE: APPLICA,`+TS SIGNATURE: CITY OF CUPERTINO BUILDNG DEPARTMENT • Rerooflwinwdrd