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R-4546 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4546 INSPECTION DIVISION PERMIT EXPIRATION • REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS 2rvrQ C .xT RESIDENTIAL-t-" 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.# ADDRESS �/L/'(�4• �I�� e/ EXISTING ROOF COVERING PHONE G 7 7 NUMBER OF EXISTING COVERINGS d A/ CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME ADDRESS TYPE OF ROOF COVERING CITY&ZIP v'r EXISTING PHONE_ gl?s2�_ �Xh BUILT-UP ROOF ❑ LICENSE NUMBER �7 Z�J 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. 0`9WOOD Class WOOD SHINGLES 39 Lic.Number Data_^ contractor G ROd�'� N S OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the fallowing 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 permit to lila a signed statement that he Is licensed Pursuant to the Previsions of the Contractor's License Law(Chapter B(commencing with Section 70)of Division 3 of the Business and Professions 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).): 0I,as owner of the property,or my employees with wages as their sale compensation,will do WOOD.SHAKES ❑ the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. dons 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 doOTHER(SPECIFY) ❑1- 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. 1 am exempt under Sec. ,B&P.C.for this reason OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: D ❑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 or which this ✓/J� /K�^ /y' permit is issued. jx. �ftm- have antl will maintain Worker's Compensation Insurance,as required by Sectlon 3700 of ( `"�-4VF-,1'4?-4- the Labor Code,for the performance of the work for which this permit Is issued,My Worker's Compensation Insurance carrier and Policy number are: OEta I C �T Carrier, Policy No. PERMIT AUTHORIZATION f%I I t of DATE' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed If the permit Is for one hundred dollars($100)or less.) r^ / 1 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 9hall be inspected prior teMny roofing material being firms. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. subje�toE eOWorrkersCC Compensation proviaftei sionis ofertificate at the Labor Code,Exemption, Iu mustuforthwlithbecome omply Applicant understands and will comply with all non point 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 correctI 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. ✓x /� //�J /� 4 sp'We, purposes. /'%i r Vii( 7 / • lWe)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities, 7 ^ judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY SUBIECI': REROOFING POLICY FOR '1.111-• CI'I'f OF CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PE1U UT AND INSPECTION PHASE. I. Prior to permit issuance, you must agree to comply wilt U.B.C. standards and nhamuf cturers spec's Oil reroofing. 2. New roof coverings shall ,at be applied without first obtaining all inspection and written approval From the building inspector. A final inspection and approval shall be obtained from Elie building inspector whert lire reroofing is complecd. 3. All types of roarsilall be inspected prior to oily roorbcing installed. d. In order to receive a final,you Illus(complete steps 1,2, and 3. I,) Preinnspectiotr or[car off approval. 2.) In progress imspecliom approval. • 3.) Final inspection approval. a.) Operable smoke deicctor vcrificalionn b.) Spark arrestor installation " 5. If plywood is installed, a plywood nail inspcciiott is required. G. If any roof is applied without first Obtaining all inspe-iion, you will be required to remove all nc'.v material down to the she�tining and a building inspector will inspr_t all slrcallling at Ural Lima WE UNDERSTAND TILE ADOVL POLICY ON RL•RGOFiNG AND WILL MYLPLY WITH THE POLICY HOMEOWNERS NANLE: ADDRESS: /ll4&1aAJ14 REROOFING CONLPANY NAME: ( /i�O O��,JU G APPLICANTS SIGNATURE: Cl'I-r Of CUPERTINO BUILDING DEPARTMENT Rcraaf/hrimrard Citil of Cupertino SMOKE DETECTOR CERTIFICATE OF COMPLIANCE 1 understand and comply with Sectio" 1210-a of the Uniform Building Code. Section 1210-a requires when repairs to a single famiiy dwelling exceed 51,000, 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 de!ectors 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: 22,/ZL PERNUT NUMBER: HOMEOWNERS SIGNATURE: DA'L'E: I winword/smkdet