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R-5368 (2)t 0 • OFFICE COPY PERMIT R_ 5368 APPLICATION FOR CITY OF CUPERTINO NUMBER 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 LASTCALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA / 1 YES ❑ If yes —1 understand that a Class A NAME _�R /fll AIV&7y /�/ roof assembly is required. NO Initial I.C.B.O. N z.` / EXISTING ROOF COVERING ADDRESS Zasl4��/� r PHONE ��' iZ f .:/ NUMBER OF EXISTING COVERINGS TO BE REMOVED TO BE RETAINED CONTRACTOR'S o / L .eoo/�✓ NAME ADDRESS yrr�CITY&ZIP TYPE OF ROOF COVERING/6 EXISTING r�V PHONE BUILT-UP ROOF ❑ LICENSENUMBER 7z7� �4 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section WOOD SHAKES 7000) of Division 3 of the Business and Professions Code, and my license Is In full farce and sneer �y�s WOOD SHINGLES ❑ License Cleae =� Lic. Number OTHER (SPECIFY) f�Lf^ 0% F �ooly Date Contractor OWNER -BUILDER DECLARATION PROPOSED / hereby eHirm that am exempt fromthe License Lew for the following reason. ✓'1 Code: Any city or (Sec. 70315, Business and e: Any city which requires e permit to V Q or to it demolish, or rep constant, alter, Improve, demolish, or repeat any structure, prior lope Issuance, also reproves the BUILT-UP ROOF / applicant for such perms to file a signed statement that Is licensed pursuant to the provisions of the Contractor's License Lew (Chapter 8 (commencing with Section 7000) at 3 of the Business and Code) or that he is exempt therefrom and the basis for the the alleged ASPHALT SHINGLES ❑ violation at exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to he e civil penalty of not more than five hundredyellers (h 1: I, WOOD SHAKES ❑ employees wag ❑ with wages as their sole compensation, wolf do as owner of the property, or to ded the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes- sions Cotle: The Contractors License Lew does not apply to an owner of property who bullas 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 to is sold within one year of completion, the owner -builder will have the burden of proving that he did OTHER (SPECIFY) not or Improve for purpose of aelc 01,ea Owner of the property, amexclulusivelycontracting with licensed contractors construct the project (Sec. 7044, Business and Professions Cotle: The Contractors License Lew does not Law PROVIDE LC. B.O. REPORT NO. improv apply to owner of property whobuilds orimprovesthereon, and who contracts for such projects with nt licensed pursuant to the Contractor's License Law, 1 Sec. 8 P. C. for this PROVIDE MFGR. INSTALLATION SPECS. am exempt under ❑ am ,B reason DATE VALUATION PERMIT FEE Owner DatePLIC WORKER'S COMPENSATION DECLARATION low I hereby eHirm under penalty of perjury one of the following declaration:J• ❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation, /n� v� 11 BuildingZ7 `, as provided lot by Section 3700 of the Labor Code, for the performance of the work for which this permit 19 ued. (,GI_` Cjj-Seismic Part5ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My Worker's Compensation Insurance Policy �6� Ilk Ce Total carrier and number era: '% Lys✓''' S7/^wG�-4% PERMITAUTHORIZATION DATE Carrier Policy No. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section need not be completed If the permit Is for one hundred dollars ($100) or lel I certify that In the performance of the work for which this permit Is Issued, I shell not employ any person In any manner so as to become subject to the Workers' Compensation Laws of Cell. All roofs S I be inspe ted prior to any roofing material being fornia. installed. If a root is installed without first obtaining an Date Applicant inspection, I agree to remove all new spection. subject 1. the WorkersOT CE TO ' Compensation proviANT: It, after sions ofthtelcate of Labor Code, ode must foibwith ompl y comply Applicant understands and will coon point Ebette7r with such provisions or this permit shall be deemed revoked. source regulations. I certify that I have read this application antl slate that the above Information Is correct.I agree to hallcity state laws F�LFBQfC$)Y2 i I or repesecountyordinancesantl hereby teruonthelatinglo ontingconspertlyfoand herebyauthorizeprp representatives of this city to enter upon the above-mentioned property for In. spection purposes. to harmless City Cupertino (We) agree and keep against Ilablllllae, save, expenses way the ai judgments, costs dna expenses which may In any way accrue against said Ciry In consequence of the granting otthis permit. SIGNATURE OF APPLICANT DATE 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 0 • • SUBJECT: REROOFING POLICY FOR TIHE CITY OF C�L'PECTINO BUILDL`1G DEPA.RTNIENT PRIOR TO ISSUANCE OF PE?`l11 i AND LNSPECiON ._'A..". 1. Prior to permit iss mncq you mus: agrr_ to comply with U.B.C. standards and manufac: sea sec's on re:coting. 2. New roof coverings shall not be aoolied witheut first obtaining all inspection and writ-,= approval from the building it sor_:or. A final ins cion and aooroval shall be ebta ne- from the building insae^_:or when the reroofing is comolet -. 3. All types of roof shall be inspe^_:ed prior to any roof being installed. 4. In order to receive a final you muR comolete steps 1, 2, and 3. 1,) P.cinspecaon or Lear off approval. 2.) In progress inspection approval. 3.) Final ince—cion. aooroval. a.) Operable smoke detector verification b.) spark arestor inst-illadOrl S. If plywood is installed, a plywood nail inspection is required. 6. If any roof is applied without first obtaining an ince uon you will be require- to remove all new material down t° the shcthia; and a building in ,e—_.ar vvu in_�G all sheathing at that time. %v� UNDERST�VW Tr-- ABOVE POLICY ON FEF NG PND WILL COMPLY WITH Tr'n POLICY HOMEOWNERS NAME: ADDRESS: ` REROOFING COMPANY NAME: APPLICA`'r5 SIGNATURE: CITY OF CUPERTINO BUILDING DE?ARTMENT Rerooflwinvvdrd -QO,04,x /?1�6i16 �C✓Sr i✓