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R-5298 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5298 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 IASTCALLED INSPECTION, BUILDING ADDRESS/ /�—� II,� Z 2-5-6 .P StIVP� LSO-- W RESIDENTIAL COMMERCIAL OTHER OWNER'S .�1 Iunderstand HAZARDOUS FIRE AREA NAME 10' `^'I r C7� 1 I L.(.ZZ(' YES ❑ If yes un Nrsreq that a Class A roof assembly Is required. NO Initial I.C.B.O.# ADDRESS �Lz.2-S"$(moo S�t/�V�-7 C� vi I EXISTING ROOF COVERING PHONE 4L�� 25'x= t�IZ / NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME )�`y I` �`-""- ("-""' `�' '� ' dry 1L TO BE REMOVED TO BE RETAINED ADDRESS �r L U�nl a�gCX /'� _I_ �-�' pS II PE OF ROOF COVERING GITYszfP 1Gr 10 �o� ! EXISTING PHONE (4N) _ 7D-449s BUILT-UP ROOF ❑ NCENSEUMBER SOS I ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION herby affirm that I em sinantler provisions of Chapter 8(commencing with Section WOOD SHAKES ]000)of Division 3 of the Business entl Professions Code,and my license is In lull force and ' effect. //'' CMn WOOD SHINGLES ❑ License CI.L LIC.Num ber I r-�C../IAt Date sal Contrado OTHER(SPECIFY) ❑ _ OWNER.BUILDER DECLARATION PROPOSED 2 I hereby affirm that I em exempt from the Contractor's License Law for the following son. �/ (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 ❑ '�✓'`C. applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter 0(commencing with Section]000)of Division 3 of the 0 • Business entl Professions Cotle)or that he IS exempt therefrom and the basis for the alleged ASPHALT SHINGLES 6I' , 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).): u 1 q ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAK I ❑ the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes- sions 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 y work himself or through his own employees,provided that ,I such Improvements are not intended or offered for sale.If,however,the building or Improvement V rrH l�1rQ 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.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's 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. ❑I am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I herby affirm under penalty of perjury one of the following declaration: �,��, ��'��""---""�IIII s ❑ have and will maintain a Certificate o Consent to sell-insure for Worker's Compensation, BUlldl permit Is Is for by Section 3700 of the Labor Coda,for the performance of the work for which this /I�/Q� hr COO ^ ` `f, permit is have _ I K•�/ Seismic 1 have end will maintain Worker's Compensation Insurance,as required by Section 3700 0l the Leber Code,for the performance of the work for which this permit is issued.My Workers F Co i{,I�nsur0 cerriacaoq icy number fur Total No. I"8�' Total Co^A.- 1; ;;- Policy PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTIO11 FROM WORKERS' COMPENSATION 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 shell not employ any person In any manner so as to become auDlect t orkers'Comp tion Lawa of call- All roofs shall be inspected prior to any roofing material being forma. installed. If a roof is installed without first obtaining an Date �_/13/9'17 Applicant inspection,I agree to remove all new materials for inspection. NOTICE subject to the Workers'Compensation after ofethelcate L born Code,yolu mustuf houl bcompl Applicant understands and will comply with all non point P P PY with such provisions or this permit shell be deemed revoked. $OUfCe regulations. - 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 All roofI $A, atter. herby authorize representatives of this city to enter upon the above-mentioned property for in- spection purposes. C S/13 (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, odgments,costs and ltlhe granting of this pePmltses which may In any way accrue against said City in consequence SIGNATURE OF APPLIC NT DATE • PRE-INSPECTION: PLYWOOD: IWPROGRE 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 BUILDNG DEPP.RTNIENT PRIOR TO ISSUA`ICE OF PERNQT AND INSPECTION PHASE. you must agree to comply with U.B.C. standards and man 1. prior to permit issuancufac:are:s sec's e, on re:cofing. 2. New roof coverings shall not be applied without first obtaining all i=ecion and wrinen 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. r 4. In order to receive a final,you must complete steps 1,2, and 3. 1,) Pre;nspection or tear off approval. 2.) In progress inspection approval. 3.) Final inspection approval. a.) Operable smoke detector veiiftcation • b.) Spark arrestor installation 5. If plywood is installed,a plywood nail inspectioa 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 Tr1E POLICY HOMEOWNERS NAME: Z "� ADDRESS::` 22SS(o St�VG✓ v ` I REROOFING COMPANY NAbIE: APPLICANTS SIGNATURE: CITY OF CUPERTINO BUILD NG DEPARTNIENT • Reroof/winwdrd