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R 4535 (2)I t i OFFICE COPY NUMBER R- 4535 APPLICATION FOR CITY OF CUPERTINO REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED Y WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS // f / 95-Z �/v kms(/ �/ RESIDENTIAL COMMERCIAL OTHER— OWNEITS - HAZARDOUS FIRE AREA `/1/�J /1 / ��0 YES ❑ If yes — I uMersland that a Class A NAME �/L / /! (/ / / G �L/ /PboI assembly is required. N �,/ Initial I.C.B.O. N A /`, ///�/ / .�'Q �.2— L EXISTING ROOF COVERING ADDRESS—./2V ����a-,yw�, J!/ `� - PHONE NU BER OF EXISTING COVERINGS //• CONTRACTOR'S NAME � TO BE REMOVEDy TO BE RETAINED ADDRESSZ `����'1 TYPE OF ROOF COVERING CITU 8 ZIP— '�! !T! EXISTING ��ZF2 PHONE d2a BUILT-UP ROOF ❑LICENSE " -- NUMBER ASPHALT SHINGLES LICENSED CONTRAC RS DECLARATION I her affirm that I am licensed under provisions of Chapter 0 (commencing with Section 7000) of DN1slOn the Bueineas Professions Cape, WOOD SHAKES end and my license is In full torte and offset.WOOD SHING(,5 ® ❑ License as Llc. Number `'u(r0 / Z X� Al Data OTHER (SP CIFYY� �.(� 79a� ❑ OWNER-BUILDER BUIL Contractor's LcenOse L hereby affirm that I am exempt Law for the fallowing 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, alsorequlrestho applicant for such to file a signed statement that he is licensed BUILT-UP ROOF ❑ permit pursuant to the provisions ' of the Contractor's License Law (Chapter g (commencing with Section 7000) 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).): I, as owner of the property, or my employees with wages as their sole compensation, will do WOOD SHAKES the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes. sions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ such Improvements are not intended or offered for sale. II, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he did 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 Lew 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 Contractor's License Law. C]I am exempt under Sec. ,B 8 P" C. for this reason PROVIDE MFGR. INSTALLATION SPECS. " owner Date WORKER'S COMPENSATION DECLARATION ' APPLICATION DATE VALUATION P MIT FEE I hereby affirm under penalty of perjury one Of the following declaration: ❑ I have and will maintain a Certificate of Consent to sell -insure for Workers Compensation, BUIL as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. �r m 0 a SBISRIIC n%-1 Worker's Compensation Insurance, as required by Section 3700 of ❑ I have and will the Labor Code, for the I/� - V l 'p _t,--rf-1V—F- ,Ihe performance pedormence of Ihark for hlch this permit Is issued. My Worker's Camps ns n Insur/e9ca ier antl Pol' umber o: V Total Cerner Policy N� 3l%, /rQ(L© PERMIT AUTHORIZATION WE CERTIFICATE OF PTION FROM WORKERS' �^ 1 COMPEN ATINSURANCE N.flO (This section need not be completed It the permit is for one hundred dollars ($100) or IeseJ I certify that in the performance of the work to ich this permit Is issued, shall not employ any person In any manner so as to become s act t the Workers' Comp anon Lews of Celb All rDOM shall be Inspected lififlor to any rodfing material being (anisn G / installed. If a roof is installed without first obtaining an Date '4L- 3_ Applicant inspection, I agree to remove all new, materials for inspection. NOTICE TO APPLICANT: It. after making this Ilicole of Exemption, you a ould become subject la the Workers' Compensation provisions a Labor Code, you must forthwith Comply Applicant understands and will comply with all non Dint pP p y p with such provisions or this permit ehalQbe dee revoked. source regulations. I certify that l have read this application and itto that the above Information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction, and Ir0 coverings to be class "C•'or better. hereby authorize of rola Illy t0 enter upon the above-mentioned properly for in. hereby purposes. '(We) agree to save, indemnify and keep harmless the City Of Cupertino against Ilabilifies, )udgmenls, costs and expenses which may In any way accrue against said City In consequence SIGNATUREJCFIAPPLICANT of the granting of this permit. 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 SUBIECI': REROOFING POLICY FOR T1113 CITY OF CUPERTINO BUILDING DEPARTivIENT PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PRASE. 1. Prior to permit issuance, you must ngrce to comply with U.B.C. standards and mauufnciurcrs specs Oil reroofing. 2. New roar coverings shall not be applied rvitlroul first obtaining all inspection and written approval From lite building inspector. A final inspection and approval shall be obtained from tine building inspector wllell lire reroofing is completed. 3. All types or roar shall be inspected prior to any roar being installed. d. In order to receive a firm], you "lust complete steps 1, 2, and 3. l,) Preinnspectioir or tear oirapproval. 2.) In progress inspection approval. 3.) Final inspection approval. a.) Operable smoke detector wrilicatiou b.) Spark arrestor installation 5. Irp]ywood is installed, a plywood nail inspection is required- . air inspection, you will be required to remove nil "c•.v G. If any raoC is applied Without first obt material down to the slrc,thing and a building inspector will inspr_t all sheathing at that 1111'e- WE lna WE UNDERS-i'AND TILE ADOVII POLICY ON �Z-RCOPING AND WILL COMPLY WITH TIIE POLICY IIONIE--OWNERS NAME: ADDRESS: REROOFING COMPANY MANIZ: APPLICANT'S SIGNATURE: CI'IY OF CUPERTINO BUILDING DEPARTMENT Rcroof/wimvord