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R-5608 1 r PERMIT APPLICATION FOR CITYEC CUPERTINO NUMB RR- 5608 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR ' 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S „ HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAME roof assembly is required. NO Initial I.C.B.O.# EXISTING ROOF COVERING ADDRESS PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME /V ADDRESS E OF ROOF COVERING cITY a zIP . (3120 Q?X 1510 EXISTING PHONE 'll BUILT-UP ROOFLICENSE ❑ NUMBER / ASPHALTSHINGLES ❑ LICENSED CONTRACTORS DECLARATION _ w hereby iaffirmnion that em Business under Professions lone of e,and g(commencing with Section WOOD SHAKES ]000)of Division 3 of the Business entl PrOlesslona Cotle,entl my license Is In lull force and effect. WOOD SHINGLES ❑ License Of LIc.Number OTHER(SPECIFY) Dat Contractor OW from th ContrDERactors DECLARATION PROPOSED j hereby affirm Bu rhes am exempt from the e: Any License Law for the lines a reason. (Sec.]ct,alt Business and Professions Code: Any city or county which requires requires permit to construct,alter,Improve,demoto file signedrepair statem ntrthat a prior co sta Issuance,also pture the BUILT-UP ROOF } or its Co for such permit a Ills a signed statement that he Is licensed pursuant to the provisions / ' of she ss and)Prof License Lew(Chapter h(commencing with Section]000)01 Dlvlslon 3 Of the Q Business entl violation of Code)of that he Is exempt therefrom and she jbasisis for the alleged ASPHALT SHINGLES exemption.Any violationofhSection five hundred by any applicant for a permit subjects the applicant to e civil penalty of not more then five by employees yeesdollars(h wag): 0I,k,and sthctureI not ty,or tended oyerswhhwages(Sec.their 44,compessatbn,will do WOOD SHAKES ❑ she work,entl the ant hecto Is nos Inse Law or offered for sale(Sac.]044,Business and Profbuilds or improves The Cant hectors time Law does not apply to an owner of property who bondsor WOOD SHINGLES ❑ Improvesothereon,and not doessuch work redhimself orthroughhis Own employees,or provided ant such improvements are not completion, leb n,or offered tar seer. ill however,for burden or Improvement is not or prove for purpose sale.).Ownerbulltlerwlll have the burtlen of proving that he did OTHER(SPECIFY) ❑ not bulb or Improve icor purpose of sele.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and ProfesslDna 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATI E VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of penury one of the following declaration: ^�,� C]I have and will maintain a Certificate Of Consent to salt-Insure for Workers Compensation, Building��L� as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit h v and ��j �,NC��©� Seismic ___�-�(_. 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 Ut'C Total Compensatl nIn rence ceryl andel Policy number are: 9/ UY �! Coul K),V� PolicyNo.1-/b PERMITAUTHORI TION DATE CERTIFCO F EXEMPTION FROM W RS' COMPENSATION INSURANCE N.C.Q (This section need not be completed It the permit Is lot one hundred dollars(510Old, less.) I certify that In the performance of the work for which this permit Is issued,I shall not employ any person In any manner so as to become subject to the workers'Compensation laws of Calf- All roots shall be inspected prior to any roofing material being fornia' installed. If a roof is installed without first o ammg an Dale Applicant inspection,l agree to remove all new materials inspection. NOT subject IoEtheWorrkers'Compensation f,after prolvisionis of thecate of Labor Code,you mustforthwith become comply Applicant nderstands and will c mply w' all non point with such provisions Or this permit shell be deemed revoked. sour ulatl - 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 At O f Over classa r. 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 and expenses which may In any way accrue against said City In consequence PPLICAN DAT • of the 9 0l this Permit. PRE-INSPECTION: ION: PLYWOOD: N-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 SUBJECT: .RE_400FR4G POLICY FOR THE CITY OF CUPERTNO BUILDD+G DEPART`IENT PRIOR TO ISSUANNICE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you must agree to comply with U.B.C. standards and rnnnufacrurets spec's on rercofing. 2. New roof coverings shall not be applied without first obtaining all inspection and «Tinea approval from the building inspector. A final inspection and approval shall be obtained from the building inspector when the reroofing is completed. 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 de,.e^_:or verinaticn • b.) Spark arrestor installation 5. If plywood is installed,a plywood 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 TI.M ABOVE POLICY ON REROOFING P_NID WILL COMPLY WITH TIHE POLICY HOiv1EOWNERS NA.VfE: ADDRESS" ` REROOFING COjvTANY NAME: APPLICANTS SIGNATURE: zn CITY OF CUPERTINO BUILDING DEPARTMENT ReroofAvinword