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R-5680Is it i MPERMIT R_ 5680 CITY of CUPERTINO NUMBER APPLICATION FOR 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 j / n =aT-rG �i }(� RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �� �� YES Class A NAME /' n rofffof assembly is reequired, Initial I.C.B.O. p �g—j� � �( EXISTING ROOF COVERING ADDRESS—�,:TJ O 4 ' 7 3 NUMBER OF EXISTING COVERINGS I PHONE 02 CONTRACTOR'S NAME S D (rli.9' TO BE REMOVED TO BE RETAINED ADDRESS'a TYPE OF ROOF COVERING X&42 CIN&ZIP / !� / // EXISTING D"' PHONE //J �77 BUILT-UP ROOF ❑ LICENSE NUMBER 7 3 ASPHALT SHINGLES J / LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section WOOD SHAKES ❑ 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and err"L (// ��% / n/ WOOD SHINGLES El License Classc Llc. Number ^� J` '�_1 THER(SPECIFY) ❑ Dale 9 :fz Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the bllowing reason. PR SED (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 provisions of the Contractor's 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 SHINGLEP $ 1:1exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to A I ® a civil penalty of not more than rive hundred dolars ($500).): SHAKES I, as owner of the property, or my employees with wages as their sole compensation, will do F] 1, ❑ the work, and the structure Is not intended or offered for sale (Sec. 70", Business and Profes. dons Code: The Contractors License Law does not apply to an owner of property who builds or �ap ��ff►► 18 ��� WOOD SHINGI[�6a improves thereon, and who does such work himself or through his own employees. provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion. the owner -builder will have the burden of proving that he did OTHER(SPEbIi`Ytr uurthllNlp 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 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 contraclons) licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑ I am exempt under Sec. ,B & P. C. for this reason Owner Date APPLICATION DATE VALUATION PERMIT 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 sell -insure for Worker's Compensation, Build as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of �/r�/ �/4� , �O v O/i/u"' Seismi the Labor Code, to e p dor nue of the work for which this permit IS Is9uetl, My Worker's Compensation uran carr and P number are: �I G C Total PERMIT AUTHOR ZATI D Carrier J� POIIcyNACN CERTIFICATE OF E EMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 (This section need not be completed If the permit is for one hundred dollars (51 00) or less.) I 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 become subject to the Workers' Compensation Laws of Cell. All roofs shai inspected prior to any oofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant insp on, lagree to remove all new materials for inspection. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should became subject to the Workers' Compensation provisions or the labor Coda, you must forthwith comply q licant understands and will Comply with all non point p y p with such provisions or this permit shall be deemed revoked. s urce regulations. 1 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 Il roofrin to be class "C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spectionrpoaea. agree (We) agree to save, Indemnify and keep harmless the Clry Caagainst liabilities, judgments, costa and expenses which may In any way accrue againstsaid Ci Clty In consequence SIGNATU 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY • SUBJECT: REROOFING POLICY FOR Tri CITY OF CUPERTINO EUII DNG DE?ART fENT PRIOR TO ISSUANCE OF PER [T AND NSPECTION PHASE. 1. Prior [o permit issuance, you Must agree to comply with U.B.C. stanc rds and r, anufzcalrers sec's on reroofing. 2. New roof caverings sball not be applied %vithout first obtaining all i=ection and wrinea approval from the building inspe-_:or. A final ir=e --,.ion and approval scall be obtained from the building inspector when the reroofing is campleted. 3. All types of roof shall be irLre•_':ed prior to any roof being installed. 4. In girder to receive a final, you m' -a complete steps 1, 2, and 3. 1,) P.einspr_don or to off apprcvrl. 2.) In progress ir=ec,don approval. 3.) Final insce_1on approval. a.) Operable smoke det =tor verincation b.) spark are_ -,or instillation • 5.. If plywood is installed, a plyvmecd nail inspection is required. 6. If any roof is applied without firs ob[aining an mspe tion you will be required to remove all neer material down to the shmthing and a buddm= tnsce^.or willin�pr_. all sheathing at that time. NVE U1,MF=,AND Tf-� ABOVE POLICY ON REROOFING PND WILL CO�<PLY Wer. TEE POLICY hOMEOWNEM NAME: ADDRESS; REROOFING COMPANY NANIE: APPLICA,`7S SIG -NAT -URE: CITY OF CUPERTINO BUILD NG DEPARTMENT 0 ReroofAvimvdrd 2 p S-96 47