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R-5675 PERMIT R- 5675 . APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR • 100 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS hPIC RESIDENI COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ If yes-I understand that a Class A NAME�� 5 C roof assembly Is required. �/�j � NO Initial I.C.B.O.# ADDRESS 4:2 .F_A�W �� Cir r ^2 j.^ 1 EXISTING ROOF COVERING PHONE —Q.213' Jc+ NUMBER OF EXISTING COVERINGS CONTRACTOR'S ///�� /J TO BE REMOVED TO BE RETAINED NAME/'f-Sr /j- �lJd � Y7 9 ADDR SES / ✓I,.LL PE ROOF COVERING CITY a ZIP /r/,/4 ^7 Q- EXISTING PHONE o�/ _�7 / BUILT-UP ROOF ❑ LICENSE NUMBER /�/5$ L Q ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am Ilcensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ]000)of Division 3 of the Business and Professions Code,and my license Is In full force and affect' WOOD SHINGLES ❑ License Class Llc.Nu bar 9 _S' Contractor OTHER(SPECIFY) Data Coor > OWNER-BUILDER DECLARATION PROPOSED hereby affirm that am exempt from the Contractor's License Law for the following reason. (Sec.7ct,alt Business and demolish, shsor rep Code: Any city or county which requires a permit to construct,alter.su Improve,to file signed staair tny ement that prior toIts Issuance,pursuant alsoreprovisthe BUILT-UP ROOF ❑ applicant for such permit to floe a signed statement that g with Section pursuant to Na provisions of the Contractor's License Law(Chapter 8(commencing with om and]000)of for the 3 of the • axee ptio and violation Of Code)or that he Is exempt therefrom and the basis for the scant to ASPHALT SHINGLES ❑ mpnon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant b e toll penalty of not more than foe hundredy employees donors(h wag): PAID WOOD SHAKES ❑I,as owner of the property,or to ded with wages as their Bole compensation,will do s. the work,and the structure is not Intended ores not for eels(Sea owner of Business and Proles- Isions mprovsth:The Contractors License Law tli self apply to an rthroughhiso own property es,who builds or WOOD SHIQ $0 WaJ) ❑ Improves thereon,entl who doessuchwork ed f off or through his own employees,provided that such Improvements are not Intended or offered for sale.If,ill however,the building or Improvement Is not or year of for purpose sale.). owner-builder will have the burden of provingthat hedid OTHER(Stp��(''``��FL�yy) ❑ not b 1,air Improve for purpose of salelu `TjD-Ui lvUYtI1I INU ❑I,as owner of the Business am exclusively contracting with licensed contractors to construct the project ownerf pr Businasa entlsProfessions mprov Code:The and who con License Lew does not PROVIDE LC.B.O.REPORT NO. apply to c ntownerof property who builds orImprovesthereon,and who contracts for such projects with a c m exempt licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS. ❑I am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION iI hereby affirm under penalty of perjury cate one of the oto self-insure declsure for Wo ❑ have and will maintain a Certificate of Consent to epeeInsure for Worker's Compensation, PAID BUlldln�, pe mitis Is for by Section 3700 of the Labor Code,for the performance of the work for whim this 2 �Ob I permit Is Issued. a ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of / 11p1 �0 p[p41 SBISRIIC -the Labor Cotla,for the performance of the work for which this permit Is Issued.My Workers VAS REE U Total Compensation Insurance terrier and Policy number are: Carrier Policy No. CI Y UI- IAERM THORIZATION All 90T�.,l CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed If the permit is for one hundred dollars($100 r s.) certify that In the performance of the work for which this permit is issued, shay of employ any person In any manner so as to become gyp t e i ere'C ansa to L sof call- All roofs shall be inspected prior to any roofing material being fornia,. /Yi �� y installed. If a roof is installed without first obtaining an Datd'0 // Applicant 1 inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemp Ion,you should become Applicant understands and will comply with all non lint subject to the Workers'Compensation provisions of the Labor Code,you must forthwith Comply pP P Y p with such provisions or this permit shalgbe 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 coy and county ordinances and state Tawe relating to building construction,and All roof coverings to be class" r better. hereby authorize representatives of this city to enter upon the above-mentioned property for in. spection purposes. h (We)agree to save,Indemnify and keep harmless the Cly of Cupertino against liabilities, Qi/i p! judgments,costs and expenses which may In any way accrue against said Cly 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY SUB7ECT: REROOFING POLICY FOR Tri CITY OF CUPERTINO BUIL.DL`;G DE?A.R%<EVT PRIOR TO ISSUA`ICE OF PERNfIT ANINSPECT ION PHASE. 1. Prior to pewit issuance, You must a;ee to comply with U.S.C. smnd=ds and n r ufac:uea sec's wan on reroofing. 2. Nc,.v roof coverings shall not be applied without first obtaining all i==.ion and wrirea aceroval from the building inspector. A final ins c on and approval shall be obtained from the building insoec:or 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 mt>_a comole:e steps 1,2, and 3. 1,) Preinscection or tear oft approval. 2.) In progress ir=e--tion approvtl. 3.) Final inspe.lon approval. a.) Operable smoke de:ec:or verification • b.) Spark arrestor installation 5. . If plywood is installed,a plywood nail inspection is required. 6. If an roof is applied without first obtaining an inspection, You wi l be required to remove all new y in_�eaor will insect all sheathing at that time. material down to the sheathing and a building NVE ENDERSTrL`ID Trz^ ABOVE POLICY ON REROOFING PND WILL COv1PLY Wl'I-t? T-EE POLICY o� HC N[EON:v cRS NAME: �?/gOD r ADDRESS; nc REROOFING COMPANY NAME: APPLICANTS SIGNATURE: CITY OF CUPERTNO BUILDING DEPARTMENT Rerooflwimvdrd CITY OF CT:,PERTLvO BUU-DINGD[VISION 403-777-3223 RE-ROOF TEAR OFF POLICY 1. You must schedule an ins:=-4oa for the tear of the day before the date you wish the ins-pection to be made. The proc:iure is to call the Building Division(777-3223)between the hours of 12 0 and 4:00 p.m- for next day iarx don. 2. When the roof is tom of, the nails removed or driven in and all of the dry ratted wood has beta replace-1, 71-MN' YOU NtUST CAU =Hrr. Ci 1 Y BU LDIN- G DIVISION. Aa ins�.or will be notified that the roof is ready, and he will respond to do the insrcion as soon as his schedule will allow. Thee are seecial hours for this se:ri=betaA=a 3:00 am. and 11:00 am., and betweea 1:00 and 3:00 p.m. • IF YOU CALL FOR*METl kR-OF=INS?ECZ'ON AND Tri JOB IS NOT READY, THE_ E WIL BE A RE-INSPECTION FEE OF S69.00 C3ARGED, WFJCH MUST BE PAID BORE ANON-rM INSPECTION IS MADE. rerooffwiaword •