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R-4529 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4529 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-322$ PERMIT EXPIRES IF WORK IS NOT STARTED • - WITHIN 180 DAYS OF PERMIT ISSUANCE OR WI180 DAUB FROM LAST CALLED INSPECTION. BUILDINGADDRESS // 1 L 0/ RESIDENTIAL COMMERCIAL OTHER OWNER'S IF HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAME o !l41i1.111:1 root assembly Is required. y NO ❑ Initial I.C.B.O.q ADDRESS �- 402%s - EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS / CONTRACTOR'S - A9A t/ TO BE REMOVED 40TO BE RETAINED NAME ADDRESS' / TYPE OF ROOF COVERING CITY&ZIP EXISTING PHONE AGD .I yv— 75/ 0 BUILT-UP ROOF Cl LICENSE NUMBER III OlIF 4 �. - ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am Ilcansod under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Coda,and my license Is In full force and effect. WOOD SHINGLES El License Of � Llc.Number r— 4F4 4 _ !O z OTHER(SPECIFY) ❑ Date Con tracto OWNER-BUILDER DECLARATION 4— W I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED - (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 OCT 95 applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions _ JJ • the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the y Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES'r ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Ur t+Ur'[ l(Ifyu aof civil penalty of not more man five hundred dollars($500).): WOOD SHAKES❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles. Ions Cc do: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 /�s such improvements are not Intentletl or olferetl for sale.If,however,me building or Improvement , Is sold within one year of completion,the owner-builder will have the burden at proving that he did OTHER(SPECIFY) not build or improve for purpose of sale.). 0I,as owner of the property,am exclusively contracting with licensed eonlill to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO. �� 7 apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑I am exempt under Sac. .B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: t r"J� I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Oct Building 1 495, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /O ! ��� permit's(as ad $elSrfllC ` "'have antl will maintain Workers Compensation Insurance,as required by Section 3700 of _merLebor Code,for the performance of the work for which this permit Is Issued.My Worker's Total Compensation Insurance carrier and Policy number are: f Carrier PolicyNo. I�lt>G26544L PERMIT AUTHORI ION DATE CERTIFICATE OF E PTION FROM WORKERS COMPENSATION INSURANCE N.C.D _ (This section need not be completed it the permit is for one hundred dollars($100)or less,) I 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 subject to the Workers'Compensation Laws of Cell- All roofs shaTI be in pected prior to any roffinj mate I b Ing. forms. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTCE TO APPLICANT: If, opisnistdemyunsurthld bcopysubject I.the Worrkers'C Compensation provisions of heL borrC oufowitthmlApplicant understands and will comply with all non point with such provisions or this pe rmlt shelf be deemed revoked. Source regulations. I certify that I have read this application and elate that the above Information Is correct.)agree to comply with all city and county ordinances and state laws relating to building construction,and All roof cove 'nos to-he class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spectionpurposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, s . judgments,costs antl expenses which they In any way accrue against seltl City In conseATE of the granting a this permit. quence SIGNATURE O APPLICANT 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 SUBIECT: RffitOOFING POLICY POR TILE CTi—f OF CUPERTINO BUILDING DEPARTMENT PR10R TO ISSUANCE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you mus( agrea to comply with U.B.C. standards and nravuf cturcrs spc.s Oil reroofing. ' 2. Nc%v roar coverings shall not be applied tvitlrout first obtaining all inspection and written approval from the building inspector. A Gnal inspection and approval shall be oblaineJ from the building inspector tivhen tine rcraoring is complcicd. 3. All types of roorshall be irspccled prior to ally roof being installed. d. In order to receive a fnnal,you unust complete steps 1,2, and 3. 1,) Preinspectioil or tear off approval. 2.) In progress ilrspcction approval. • 3.) Final iuspectiou apploval. a.) Operable smoke detector verification b.) Spark arrestor installation 5. If plywood is inslallcd, a plywuod nail inspection is required. G. If any roof is applied witliout first obtaining an inspectiau, you will be rcluited to remove all nc.v material down to the slrc,tlniug and a building inspector will inspect all slic.thing at that lima WE UNDERSTAND 'I,IT A130VC POLICY ON IZE•RGOFiNG AND WILL CONI-PLY WITI1 TI1E POLICY IIONIEOWNERS NAME: ADDRESS: REROOFING CONIPANY N,kNIE: APPLICANTS SIGNATURE: . CI'1'f OF CUPERTINO BUILDING DEPARTMENT RcrooUuimcord Citli of Cvperlino SMOKE DETECTOR CERTIFICATE Or COMPLIANCE I understand and comply will, Section 1210-a of the Uniform Building Code. Section I210-a requires when repairs to a single family dwelling exceed 51,000, a smoke detector will be• installed, mounted all 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 e..-cisting smoke detectors comply, no new detector shall be required. I understand the above requirement and certify (fiat we now have smoke deleciors installed that do comply. nn ADDRESS: 21100! �E6 NRJe7" K9069b v�/! PERIYUT NUMBER: " ' y S 2 9 HOMEOWNERS SIGNATURE: Lj 7�it�eN'fy DA'L'E: l 7 9 yS winword/smkdet