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R-4697 APPLICATION FOR clTv of cuPERTINo NU BER R- 4697 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 t r . RESIDENTIAL COMMERCIAL OTHER OWN 'S p HAZARDOUS FIRE AREA p �C '/'>�n.B� YES ❑ Ifyes—Iunderstantlthata Class A. NAM l/ roof assembly is required. l NO Initial I.C.B.O.N ADDRE ts 1-/ 7 (5kQ 1Q Ck`k EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS R CONTRALTO •/r— 0 NAME /" �6 O .( ,L) TO BE REMOVED TO BE RETAINED ADDRESSTYPE OF ROOF COVERING CITY&ZIP / P�"` o/� �Se 9'S�� . O ) EXISTING PHONE iYO ag 6l z 2 o BUILT-UP ROOF ❑ LICENSE NUMBER `/7 3 3 S ASPHALTSHINGLES ❑ 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 effect. WOOD SHINGLES ,`9 (� License Class Lic.Number 7`� _ Date 0 �y �qs Convector a u /✓�� 00 [i✓ OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am 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 for such parmit.to file a signed statement that he Is licensed pursuant to the provisions . 01 the Contractors lhense Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Profs ions 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 for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): [3 1. .SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- slons Code:The Contractor's License Law 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 such improvements are not Intended or offered for sale.ll,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(SPECIFY) ❑ not build or improve for purpose of sale.). ❑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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. 1 am exempt under See. .B 8 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: <': 'J ✓� ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is haveetl. / Seismic I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of V "xY the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's CI I�'(Ih 19 �� Total Compense��u!6as9urence carrier end Policy number are: + R Carrier J��� �ND Policy No!r`r .ri U. *riaoo 0 PERMITIAUTHORIZATI N f DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NC.-] (This section need not be completed if the permit Is for one hundred dollars($100)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 Call- All roofs shall be inspected prior to any rooting material being fermis' installed. If a roof is installed without first obtaining an Date Ati Imam inspection,I agree to remove all new materials for inspection. NOTICE ecome subject to the OWorkers'Compefnsation provi,after sions of the flLabor Code,cate of yalu mustufothwshoulithbcomply Applicant understands and will comply with all non point with such provisions or this permit shal.be deemed revoked. Source regulations. I certify that I have read this application and state that the above information is correct.(agree to comply with all city and county ordinances and state laws relating to building construction,and All roof coveri gs to be class"C"or better. hereby authorize representatives of this city CO enter upon the above-mentioned property for In- spection purposes. r /;y Q (We)agree to save, indemnify and keep harmless the City of Cupertino against liabilities, Q _ J I.-- / / judgments,costs and expenses which may In any way accrue against said City in consequence ICANT DATE of the granting of this permit. PRE-INSPECTION: PLYWOOD: I&PROISRESS: 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 CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's on reroofing. 2. New roof coverings shall not be applied without first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall be obtained from the building inspector 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 must complete steps 1,2, and 3. 11) Preinspection 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 inspection is required. 6. If any roof is applied without first obtaining an inspection, you will be required to remove all new material down to the sheathing and a building inspector will inspect all sheathing at that time. WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE POLICY HOMEOWNERS NAME: T07Ce �0 "00 j ADDRESS: °� 1 /J ILI C�)D"11 , /o C REROOFING COMPANY NAME: P�a/k0 V t;1, `I—O a l/J°v APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTMENT • Reroofhvinword _ low, i lie ctv of \ Cupertino SMQKE DETECTOR CERTIFICATE OF COMPLIANCE I understand and comply with Section 1210-A of the Uniform Building Code. Section 1210-A requires when repairs to a single family dwelling exceed $1,000, 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 that we now have smoke detectors installed that do comply. ADDRESS: r PERMIT NUMBER: HOMEOWNERS SIGNATURE: C JI DATE: �7e� 1 A 1 q 415 winword/smkdet Printed on Recycled Pooer