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R-4551 (2) PERMIT R_ APPLICATION FOR CITY OF CUPERTINO NUMBER 45 51 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, BUILDING ADDRESS �� yba 4 .+ 3 rt lA � Q RESIDENTIAL ' COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA /•1 r• !7 i YES ❑ If yes—I understand that a Class A NAME r• lJ ; R'll r-e- __ aot assembly is required. NO C� Initial I.C.B.O.N ADDRESS//I� W aL`V1 U.I �L�Qi EXISTING ROOF COVERING PHONE C /G NUMBER OF EXISTING COVERINGS CONTRACTORS _ NAME,r/r4✓I S (✓ , �O TO BE REMOVED TO BE RETAINED if f0 ADDRESS 0 •j�dx /J1 � 97�t (-" q EXISTING TYPE OF ROOF COVERING CITVBZIP� �JJ 4.A97`i--95. T�r PHONE /'�� `J c7— 3 BUILT-UP ROOF ❑ LICENSE -3 ,n NUMBERASPHALT SHINGLES E] 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 force and effect' WOOD SHINGLES ❑ License Class -355 LIc.Number / 3 oats � 'S�cYJ contractor OTHER(SPECIFY) ❑ OWNER�BUILDER DECLAFA I PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following 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 oro the ss and Prof License ions Lew(Chapter h(commencing with Section 7000)of Division 3 of the / Business and Professions Code)or that he Is exempt therefrom and the basis for the applicant to ASPHALT SHINGLES tlptI exemption.Any violation of Section 703 hundred by any dollars($5 pet for a permit subjects the applicant to a civil penalty of not mora then five huntlretl yees (h wag): WOOD SHAKES ❑I,as owner of the property,or to employees with wages as their sola compensation,will s. ❑ the work,and the structure a not intended ores not for sale(Sec.7044,Business and builds o- Improvotle:The, intrectors License Law tli ser apply ghhiso n employers,who rovidedsor WOOD SHINGLES ❑ Improves thereon,antl who does such work himself or through his own employees,improvement provided that such Improvements year are not intended oro wnetl for sale. ill however,the buildingofpr or improvement Is led hot or prove for purpose sale.).Owner-builderwillhave the burden of provingthat hadid OTHER(SPECIFY) ❑ 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. 1 am exempt under Sec. .B 8 P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICAAON)DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: 1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, AUG 0 �� Buildin as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this U A� par Isiesuad /+ I O �(/� Seismic •^ 11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Cly/�r the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's V uurtk��N Total 'Compensation Incur candler ca/er antl Pollc umber are: _ U Care �f�Hl Policy NM S � _3g PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.Q (This section need not be completed If the permit Is for one hundred dollars($100)or less.) certify that in the performance of the work for which this permit Is Issued, shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roof shall be inspected prior to any roofing material being forma. installed. If a roof is installed without first obtaining an Dale Applicant inspection,I agree to remove all new materials for inspection. NOTsubject lCE TO APPLICANT: If,l.the Workers'Compensation provisions o iheftabor CooyyExemption,you ufoinwith comply Applicant understands and will comply with all non point with such provisions or this permit shalgbe deemed revoked. source regulations. I 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 IAII O CO rl It b 4s, "C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection n- _ sp epurposes. Wz/L' (We))agree to save.Indemnity and keep harmless the CIN of Cupertino against liabilities, '✓ judgments,costs and expenses which may in any way accrue against said City in consequence SIG ATUR 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY • SUBJECl': REROOFING POLICY FOR TRE CI'IY OF CUPERTINO BUILDING DEPARTNLE?rf PRIOR TO ISSUANCE OF PERIyLIT AND INSPECTION PHASE. I. Prior to permit issuance, you "rust agree to comply with U.H.C. standards and manuf ciurcrs spews on rerocring. ' 2. New roof coverings shall not be applied without first obtaining all iuspec:iou and written approval from Ilre building inspector. A final inspection and approval shall be obtained from the building inspector wilerr lire :croofnug is completed. 3. All types or roorsliall be inspected prior to any roorbciug installed. d. In order to receive a final,you must complete steps 1,2, and 3. I,) Preinspectian or Lear off approval. 2.) Ln progress inspcctiou approval. 3.) Final inspection approval. • a.) Operable smoke detector veririca(tou b) Spark arrestor inslallatieu 5. lrplywood. is installed, a plyivued limit inspection is rcquircd. G. Ir any reor is applied without Ilrst obtaining an inspection, you will be required to remove all new material davit to lire shclhiug and a building inspector will inspect all sheathing at Ural tiuia WE UNDERSTAND TILE A13OVI: POLICY ON RERCOFING AND WILL CMAPLY W1Ti1 TILE POLICY IIONLEOWNERS NAb1E: c- 1 __ tn 11 ADDRESS: � Y6 A " D' Y Y�.`LLu ��rP 4, REROOFING COMPANY NAME: APPLICANTS SIGNATURE: Cl'I"Y OF CUPERTINO • BUILDING DEPARTMENT Rcrcoflvrinword