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R-5279LJ OFFICE COPY PERMIT R- 5279 APPLICATION FOR CIN 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 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIA_ COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �-a a (I CkIA0VYES ❑ It yes — I understand that a Class A NAM W LJ �s /n roof assembly Is required. NO - Initial I.C.B.O. N 11J ��1 �t ���� If EXISTING ROOF COVERING ADDRESS w'y`-'� j PHONE NUMBER OF EXISTING COVERINGS I CONTRACTOR'S '� TO BE REMOVED TO SE RETAINED NAME`. ( l�--iC'Yl h�� ADDRESS 4C-71 FR F VER CITV&ZIP ��IIJJ �,1/�,.'-� 1� EXISTING I (S- Q.�' (c PHONE `LA f `c�asLICENSE BUILT-UP ROOF NUMBER LJ ASPHALT SHINGLES ❑ ✓✓✓���"' LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter g (commencing with Section WOOD SHAKES 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Q O WOOD SHINGLES ❑ License C ss Lic. Nu er �y OTHER (SPECIFY) ❑ Dale Contra OWNER BUILDER DECLARATION P A 1Vt V PROPOSED hereby affirm that am exempt from the Contractor's License Law following reason. (Sac. 70315, Business and Professions Code: Any city or countywhichich requires a permit to anystructure, Is licensedor to Its requires the construct,applicant otter, improve, demto file he la licensed for file BUILT-UP ROOF ,APR - 8R91 pursuant to the provisions such permit to a signed statement that pursuant signed statement of the Contractor's Law (Chapter 8 (commencingwitheref Section 7000) of Division 3 of the of the Contractor's Business and Professions Code) or that he Is exempt and the basis for the alleged sense ASPHALT SHIN exemption. infero byany applicantlore permit subjects the applicant to s of ore v thaSecn civilpeltyof five hundred ): e civil penalty of not more then five hundred dollars (h WOOD SHAKES I, as owner of the property, or wag their sole compensation, will do employees with wages ❑ to the work, and the structure Is not intended or offered Tory (Sec. 7044, Business and Profes- (S sionCotle: Th. to License Law does not applyloanownerofproperty who or WOOD SHINGLES ❑ ,an who improves thereon, and who does such work edf off or through his own employees, provided that idedt such improvements are not or offered for sale. however, the hulloing or Improvement leb n, Is completion,ill owner -builder will have the burden of proving that he did OTHER (SPECIFY) ❑ sthe not build or Improve for purpose al sale.). notsold bull or prove for purpose 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law 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 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 PERMIT FEE WORKER'S COMPENSATION DECLARATION ,t '1 1 Buildini I hereby affirm under penalty of perjury one of the following declaration: have and will maintain a Certificate of Consent to for Worker's Compensation, Performa permit is Is for by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ I have and will Worker's Compensation Insurance, as by Section I I ^ / PS G_ l SeismlgI 1 the performance ins Labor Code, for the performance of the work for which ihl9 permit is Issued. My Worker's permit Worker's 's Total CompennsattioLn In urance carrier and Po II number are: {,� _ tl I� �4 PERMIT AUTHORIZATION DATE carrier-�"1""`� J_k^r1\ POIIC�d CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed II the permit is for one hundred dollars (8100) or less.) y 1 certify that in the performance of the work for which this permit is issued, 1 shell not employ any person In any manner so as to become subject to the Workers' C peneat Lawa of ca11- All roofs shall be inspected prior to any r offing aterial being q �� r fomData installed. If a roof is installed without first obtaining an Da,a� / Applicant inspection, I agree to remove all new materials for inspection. NOT become subject lCE l. ttheOWourPLICANT: If, after rkare Compenset on pruivisionis of thelcate of Labor Code, you mustwithcomply Applicant understands and will comply with all non point with such provisions or this permit shi lgba deemed revoked. Source regulations. I certify that I have read this application and state that he above information Is correct. ) agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for In- hereby purposes. All roof coverings to l'\�laass/"Co" orbefteer. .�j'^ C� (We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, JI judgments, costs and expenses which may In any way accrue against said City In consequence of the granting of this permit. SIGNATURE OF APPLICANT DAI` 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 CUPERTNO BUILDUgG DEPP.RitiIENT PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE. ee to comply with U.B.C. standards and manufacturers sec's 1. Prior to permit issuance, you must agr on rercofing. 2. New roof coverings shall not be applied without first obtaining all insperion and written approval from the building inspector. A final in_recdon and approval shall be obtained from the building inspector when the reroof ng is completed. 3. All types of roof shall be inspe•_'ted prior to any roof being installed. ' 4. In order to receive a final, you must complete steps 1, 2, and 3. 1,) Preinsection 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 insection is required. o inspection, you will be required to remove all new r. 6. If any roof is applied without first obtaining an s ' 0.Y q material down to the sheathing and a building inspector will inspect all sheathing at that time. • WE UNDERSTAND THE ABOVE POLICY ON REROOFING PND WILL COMPLY WITH THE POLICY HOMEOWNERS NANIE. �� ADDRESS: REROOFING COMPANY NAME: APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTNIE`1T Reroofhvinw6rd