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R-5304 (2) PER APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5304 INSPECTION DIVISIO�l PERMIT EXPIRATION REROOF PERMIT (40B�7-32L✓� " 1 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR Z Y 180 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS 1 O 6©O RESIDENTIAL COMMERCIAL OTHER DWNER's ( nunderstand HAZARDOUS FIRE AREA NAME m\1 vv --S /7�tC.�Cl-Q. YES ❑ If yeas I assembly req that. Class A roof -I un l Ia required. NO ❑ Initial I.C.B.O.k ADDRESS EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS / CONTRACTOR'S ��.. ��qq qq TAME lit erCr N TO BE REMOVED TO BE RETAINED ADDRESS Q k .3 TYPE OF ROOF COVERING CITYB ZIP ` � III VA O N .�-C KMS / 3 b EXISTING PHONE BUILT-UP ROOF ❑ LICENSE NUMBER Zq ASPHALT SHINGLES El LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provislons of Chapter an Ing with Sectio WOOD SHAKES 7000)of Division 3 of the Business and Proleselons Cod- my Iicens Is In lull force en effect. 2 OD SHINGLES ❑ License Class C-3!1 Llc.Number 6� Data �-23'�� Contractor THER(SPECIFY) ❑ OWNER-BUILD CLARATION I hereby affirm that I am exempt fro ant actor's License Lew for the lowing 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 file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law Chapter B(commencing with Section 7000)of Division 3 of the Business entl Proleselons Cotle 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 e civil penalty of not more than five hundred dollars(3500).1: WOOD SHAKES 01,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. slons Code:The Contractor's License Lew doegnot pplytoon ownar of property who buildsor WOOD SHINGLES ❑ v/ Improves thereon,and who does such work hi Ball through his own employees,provided that / y I Such Improvements are not completion, leb n,th a offered fors e.Ii, waver, aentof pros Improvement /' (_-_�( nIs t ld build oImprovyear for purpose salleo tier bulltl rwl eat intent of provingthat hedid OTHER(SPECIFY) 1,IKY1 ' r not build Or Improve for purpose of sale.). I,as owner of the property,am exclu I at contr g t licensed contractors to construct the project(Sec.7044,Business end Pro I ns Co T C ntractor's License Law does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who buildsrovest reon,a d who contracts for such projects with a contractor($)licensed pursuant to a Contractor's License Lew. PROVIDE MF INSTALLATION 711 em exempt under Sec. ,B 8 P.C.for this reason . S, C>5• OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PE IT 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 Worker's Compensation, �Q Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which lhle , / permit is Issued. ��/� Seismic 'UO ❑I have 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 carrier and Policy number are: Total •�-q7 ell 131 O carrier �.A'Tff �C//Vf� Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' �z COMPENSATION INSURANCE N.C.I] p•f (This section need not be completed If the permit Is for one hundred dollars($1001 Or leas.) ti.7.�tiL./CC / 25`s y I certify that In the performance of the work for which this permit Is Issued,I shell not employ V any person In any manner so as to become sub)p t to the workers'compensation Laws of Cali. All roofs shall be inspected prior to any roorfing material being fornia. llv/ installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. subject to EheWOPkeraCCompensetbn provlafter ilooe olthefiLabocate�Cotlemy0lu must0lorthwlah comply become Applica erstan and will comply with all non point with such provisions or this permit shall be deemed revoked. sour regulations. - 1 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 laws relating to building construction,and A oof coverin to "or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs end expenses which may In any way accrue against said City In consequence TORE OFA LIGAN DATE • of the granting of this permit. PRE-INSPECTION: PLYWOOD: IN-PROG S: INSP. DATE INSP. E 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 THE CITY OF CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PER,bIIT AND INSPECTION PHASE. 1. Prior to permit issuance, you must agree to comply w th 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. 4 a 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 plvwood 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 WITH THE POLICY HONIEOWNERS NAME: ADDRESS: REROOFING COMPANY NAME: APPLICANTS SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTMENT Reroof/winword