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R-4906 PERMIT R_ APPLICATION FOR CITY OF CUPERTINO NUMBER 4906 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-',3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR • - 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS Zv 2.f v / RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �� YES ❑ If yes s I understand that a Class A NAME eoi assembly is requiretl. NO Initial I.C.B.O.N ADDRESS 2D 7 Z S' flin/Q�S� 1J.IC. EXISTING ROOF COVERING PHONE yU 0 ZS Q NUMBER OF EXISTING COVERINGS CONTRACTOR'S • NAME TO BE REMOVED_ TO BE RETAINED ADDRESS TYPE OF ROOF COVERING CITY s ZIP TIN PHONE BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby inion that em Business licensed under provisions of Chapter y(commencing with f Section WOOD SHAKES ]000)of Division 3 of the Business end Professions Code,and my license is in full lone and effect. WOOD SHINGLES License Class Llc.Number Date Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Lew for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,ager,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 it licensed pursuant to the provisions r'r� I� E D of the DOeor such LechLicense Lew(Chapter a(commencing with Section]000)of Division 3 of the I'LryJ III IxJ' • _ Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHlryld S exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of net more than five hundred dollars($5001): WOOD SHAK DEC (r I�I_ C]1,as owner of the property,or my employees with wages as their sale compensation,will do U4J l 95 the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- LJ 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.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(sPI36[lON) INSPECTION®EPARTMFNT not build or improve for purpose of sale.). C]1,as owner of the property,am exclusively contracting with licensed contractors to construct (��Ty (gyp (r�ffIIPERTINO the project lase.7044,Business and Professions Code:The Contractors License Low does not PROVIDE I.C.B.O.AMN0. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exe of under Sac. BA P.C.fpr this reason T ~`� �i4` a Date �,�� WO COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE hereby affirm illundermaintain of perjury one of the following self-insure r Wo ❑Ihave ed(andorb Section l3700 of thei Labor ate bol Consent the perorma for worker's Compensation, Building as mitis Is for by SectlOn 3]00 0l the Labor Coda,for the pedOrmanca of the work for which this permit is Issued.and ❑ have entl will the performance Worker's Compensation Insurance,as required by Section 3700 of j S21S(f11C 0L the Labor Code,for the performance al the work for which this permit is issued.My WorkeYs 9? j Compensation Insurance carrier and Policy number are: Tota Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed If the permit is for one hundred dollars($100)ar less.) I tartly 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 Subject t the workers'Compensation Laws of call- All roofs shall be inspected prior any roofing material being fornla. f installed. If a roof is installed without first obtaining an Date AllApplicant inspection,I agree to remove all new materials for inspection. NOTICE o A ucANT: If,offer makIrg this_CortRA6ars of on,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Co e,you must forthwith comply PP P Y P with such provisions or this permit shall be 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 city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in- spection purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, L judgments,costs and expenses which may In any way accrue against said City In consequence• N TOR FAP C DA TE al 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 THE CITY OF CUPERTNO 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. 1,) 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: �� /2 '��</ ADDRESS:. 2c� ZSR Si/It�P>S/ /J2 REROOFING COMPANY NAME: e APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTMENT • Reroof/wimvord