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R-5291 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5291 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. BUILDIIN,G/ADDRESS /'�( v`L'C 'A U'('r RESIDENTIAL COMMERCIAL OTHER OWNER'S fI HAZARDOUS FIRE AREA YES ❑ If yes–I u NAME I t"'� v�L I understand that a Class A /root assembly is required. J r ( G NO r Initial LQB.O.N Wei e�5 Ch��1��` pr' EXISTING ROOF COVERING HONE ZSrI � �-7 NUMBER OF EXISTING COVERINGS ' �� � 1 CONTRACTOR'S /^� 1k SP.hSiA...s ` TO BE REMOVED TO BE RETAINED IkDDRESS NAME �7' �ly `NLG.. CITY&ZIP 994 di f, � f SA.-Jo X. 9670 TYPE OF ROOF COVERING � �1 EXISTING PHONE //��ct /— 2_ 44S37- BUILT-UP ROOFLICENSE ❑ NUMBER S 130 ASPHALT SHINGLES [� 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. �nx WOOD SHINGLES Vl License Claes `� LIc.Number �f 3 l ❑ 31 J JW ",I 1�,9 "" �'F7tiL1 l OTHER(SPECIFY) � ElDate Contractor J OWNER-BUILDER DECLARATION PROPOSED 1/ hereby affirm that am exempt from the Contractor's License Law for the fallowing reason. (Sec.construct, It Bullnose and Professions Code: Any city or county which requires a permit to c' construct,alter,Improve,demolish,a signed or repeat any structure,prior to its issuance,also requires the BUILT-UP ROOF 7� ❑ applicant tr such permit to flaw aChapt statement that he is licensed pursuant to the provisions the . of the Contractor's License Law(Chapter 9(commencing with Section 1000)of for the 3 of the Business and Professions Coda)or that he is exampt therefrom and the bells for the applicant t0 ASPHALT SHINGLES exemption.Anyviolationoltlonet Section hundred byany applicant for a permit Subjects the epplicent io a civil penalty of not more than five hundred yellers(h wag): WOOD SHAKES ❑I,as owner of the property,or to employees with wages as their sole compensation,will s. ❑ the work,and the structure is not Intended or offered for sale n owner4 f Business and Plds or isions mproves The Contractor's License Lew does not apply toenowner of property who buildsor WOOD SHINGLES ❑ improves thereon,and who does such work himself or.If,how his own employees,Improvement that such Improvements are not Intended orow offered for sale. ill however,the building pr or Improvement ntbuild sold or prove for purpose of stheownerbuiltlerwill have the burden of provingthat hadid OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,em 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 Lew PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Date APPLE NL DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury one of the following declaration: -11 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, no Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this FEB 4 �U S`i�'3 pe mit Is Issued. 41 G Seismic I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of r th Labor Code,for the performance of the work for which this permit Is issued.My Worker's C(7Y Qh VU��H I)N ) 'Compensation�Insurance `carrier er1�df PoliJp'y number re: ,I Total Carrier 9,0"�Z IOA.�n Ill No. IZ83'1401 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTIO FROM WORKERS' I COMPENSATION INSURANCE N.C.❑ K Cq (This section need not be completed If the permit Is for one hundred dollars($100)or leas.) 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 can All roofs shall be inspected prior to any roofing material being forma' installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. subject NOTICE theOWorrkerss'Compensation tl n proavisions ctthis ehe11cate of Laborr Code,you must forthwitlhbecome comply Applicant understands and will comply with all non point with such provisions or this permit shalllbe deemed revoked. source regulations. I certify that I have read this application and stere 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- spectlon purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, (kL-lw,il_ 31 JAV e4-7 judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE-OF APPLIC T DATE • of the 9rof this Permit. PRE-INSPECTION: ION: 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 TPM CITY OF CUPERTNO BUTLDNG DEPARTMENT PRIOR TO ISSUANCE OF PERN"T AND INSPECTION PI-LASE. e, You must agree to comply with U.B.C. standards and manufac tiers spec's 1. Prior to permit issuanc on reroofing. 2. Ne•.v roof coverings shall not be applied without first obtaining all inspection and wvrinea approval from the building inspe•_'toi. A final in_sDection and acoroval shall be obtained from the building inspector when the reroofing is comoleted. 3. All types of roof shall be inspected prior to any roof being installed. 4. In order io•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 verivation • b.) Spark arrestor installation 5. If plywood is installed,a plywood[tail 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 inspe.-or will inspr_,all sheathing at that time. WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COb1PLY WITH Th'E POLICY HOivfEOWNERS NAME. 1-W i I T r�lu t El t &(_a d --D>z . ADDRESS. REROOF'Ti 1G COMPANY NAME; PM APPLICA,N S SIGNATURE: CITY OF CUPERTINO BUILD NG DEPARTMENT Reroof/wvimvord