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R 524814 F- L_J OFFICE COPY - PERMIT R- 52 4 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 o 00,1/ ��-z,SO Zl;f 1af Q RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ If yes - I understand that a Class A NAME roof assembly is required. NO ❑ Initial I.C.B.O. xd.? S"o EXISTING ROOF COVERING ADDRESS PHONE y0� p�s` _ ra1�C/ NUMBER OF EXISTING COVERINGS CONTRACTORS NAME Pty /91P� /Cd0�J9. TO BE REMOVED TO BE RETAINED _� ADDRESS T S®tea, / / /^ 7'� TYPE OF ROOF COVERING CITYBZIP EXISTING ////// 7 �s/�� �/r PHONE__ �,Wn `�'r0� BUILT-UP ROOF ❑ CENSE 5'0.7 NUMBER 5-'Y,3 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby aKlrm that I em 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 e"eat C qWOOD D SHINGLES ❑ O<enee Cleve Llc. Number -5 Date Conirac.o , * /dam OTHER (SPECIFY) ❑ ECL OWNER -the 1 hereby affirm that am exempt from the Con License Lew for the following PROPOSED e: Any t. (Sec. 7031.5, Business and Professions Code: Any dry or county which requires a permit to or county permit V DL construct, alter. Improve, tos Issuance, the BUILT-UP ROOF P A LJL-J� to file signed staeny mentrthate, Iprior applicant for such permit to flaw a signed statement that he Is Ilcensetl to the the pro of the License Lew (Chapter (commencing with Section 7000) of of the 7000) of D 3 of the - ss and h and the jbasisis for the alleged for the antl violation of Code) or thet he Is exempt applicant a exemption. Anyf violation of ionfive 7031.5 by any s for a subjects the applicant to ASPHALT SHINGLEMT 2 9 q�$ civil pen. permit more than e civil penalty of not mora Than /ave hundred dollars ($500).): ($500). 1.706 ❑I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure Is Intended for Sec. Business J WOOD SHAKESEJ Or not or offered sale 7044, - and Prolesliqu saone Code: The Contramor's License Lew does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through has own employees, provided that arc WOOD SHINGLES El 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 .111 have the burden of proving that he did OTHER (SPECIFY) El"W0,9"! not build or Improve for purpose of sale.). ❑ 1, as owner of the properly, am exclusively comrecdng with licensed contractors to construct the project (Sec. 7044, Business and Professors Code: The Contractor's License Low 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. ❑ I em exempt under Sec. is $ P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compensation, eepro for by Section 3700 of the Labor Code, for the performance of the work for which this 0eiv 910 Building Is anIssued. padahave have end will maintain Warker'e Compensation Insurance, as required by Section 3700 of v ��� $eleml0 ih Labor Code, for the performance of the work for which this permit Is Issued, My Worker's Compensation Insurey ce carrier and Palms number ere: Total / Carrier f7 �r7�C �Jsa� PD11cyNo. 5'6 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section need not be completed It the permit is for one hundred dollars ($100) or less.) /D� 0� I certify that In the performance of the work for which this permit Is Issued, I shell nal employ All roof a inspected prior to any roofing material being any person In any manners as to became subject tot a Works a Compensation Lewe of Cell. 'ornia' p // installed. If a roof is installed without first obtaining an Date ..�0 / Applicant 'Of_.0/Loa inspection, I agree to remove all new materials for inspection. subjectOto Eh WorkaaCompenaeiion previsionas ofethe'Icatfrof Laborr Code, Exemption, mustforthwou lllhbecome comply Applicant understands and will comply with all non point with such provisions or this permit shell be doomed 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 Jews relating to building construction, and All roof coverings to be class "C"or better. hereby authorize representatives of this city to enter upon .he above-mentioned property for in. �7 ep ctlon(We) purposes. (Ws) agree save, and keep harmless the City Cupertino against liabilities, hj�/�i.��' A /� 341 8 s against judgments, coats end expenses which they in any way accrue egelnal Geld Clry In eoncequenca expenses s DATE $lUNATU OF APPLICANT 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 W WI SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEP.4RTv1ENT PRIOR TO ISSUANCE OF PER.bIIT 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 WfI'H TFiE POLICY HOMEOWNERS NAME: ADDRESS: REROOFING COMPANY NAME: APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDNG DEPARTMENT Rercof/winword �P4J q G JJon / tle: ll/�O