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R-53450 0 OFFICE COPY PER R- 5345 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 LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER owN 's HAZARDOUS FIRE AREA YES El It yes - I understand that a Class A NA roof assembly is requiretl. NO Initial I.C.B.O. # Z S'--�.d EXISTING ROOF COVERING ADDRESS NUMBER OF EXISTING COVERINGS r'Jy TO BE REMOVED O N TO BE RETAINED O �� PHONE ,_j CONTRACTOR' NAME L �� a /e0 D F e /r.7 �-7S ,s ADDRESSr TYPE OF ROOF COVERING S' CITY & ZIP / _?CLc�T— EXISTING A4-0 PHONE 4 o BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section WOOD SHAKES 7000) of Division 3 0l the Business and Professions Code, and my license is In full hrce and ella`t' /° � 3 / WOOD SHINGLES ❑ License Class Lic. Number $ w9 L ��I� OTHER (SPECIFY) ❑ Date Contractor T,VCiTwJ OWNER -the DEC's PROPOSED S(/ LicenON se hereby affirm that I am exempt from the Contractor's License Lew for the following reason. Conn (Sec. 70315, Business and Professions Code: Any city or county which requires a permit toconst G anystructure, issuance, also requires the alter, improve, demto BUILT-UP ROOF ❑ file signed statement is licenseorto applicant file a signed that he is licensed pursuant to the provisions applicant for such permit the of the License Lew (Chapter (commencing ereh Section ]000) of Division 3 al the a r 9 (comm �r ' ssContractor'sanPo h Business and Professions Code) or that he Is exempt therefrom and the basis for the tl ASPHALT SHINGLES ❑ exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicanticant to e civil penalty of not more than five hundred dollars (h ): yx WOOD SHAKES wages as their sole compensation, willdo ❑i,ea owner of the property, or wag ❑ Cmy ededemployeeswith for sale (Sea s - Business entl Proles- the work, and the structure is not intended ores The, Contractor's not owner of License Lew does elft apply to an owner of property who builds or WOOD SHINGLES ❑ ImproCotle: a Improves thereon, entl who does such work himself or through his own employees, d provided that Improvements Intended for are not sale, ill however, the building or Improvement such Improvement or owner -builder ntbuilsold d year theOwner-builderwillhave the burden of proving that hedid OTHER (SPECIFY) or provfor purpose of not build or improve for purpose of sale.). 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 Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. [:]I em exempt under Sec. ,B & P. C. for this reason Owner Date APPLICATION ATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑l have and will maintain a Certificate of Consent to self -insure for Workers Compensation, - Building as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit Isis APR 1 REC p and t ❑ 1 have end will maleate Worker's Compensation Insurance, as required by Section 3700 of %t7 '�'% Sei mi the Labor Cotle, for the performance of the work for which this permit Is issued. My Worker's -Compensation Total Insurance carrier and Policy number are: 'Ut'Eli I )N 4ilyl Carrier Policy No. PERMIT AUTHORIZATION DATE " CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.I] (This section need not be completed If the permit is for one hundred dollars ($100) or leas.) 1 certify that in the performance of the work for which this permit Is issued shell not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cali All roofs shall be In ected prior to any roofing material being foals. installed. If a roof is installed without first obtaining an Data / — / _57 Applicant %,Z:!:� ©' -..�. inspection, I agree to remove all new materials for inspection. too the APPLICANT. o ersCC mpensibn provisions eo Certificate subject Code, Exertion must forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shalfbe 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 All roof coverings to be class "C"or better. hereby authorize representatives of this city to enter upon the some mentioned properly for in- spection purposes.7�- �_�._ r (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, ,,,,� (/ ♦ y_ - judgments, costs and expenses which may In any way accrue against said City in consequence of the granting of this 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 SUBJECT: REROOFING POLICY FOR Tf-a CITY 'OF CUPERTPIO BUILDLN; DEPA 'n,, NT PRIOR TO ISSUANCE OF PERNU T k D D4SPECTION P LkSE. 1. Poor to ne mit issuance, you mus., a; r_ to comply with U.B.C. standards and tnanufacesea sec's an re:cofing. 2. Ne•.v roof coverings shall not be applied without first obtaining all in_-ectian and vvriaen approval from the building insoe^_:or. A final inspection and ancroval shall be obtained from the building inspector when the rereafing is comeleted. 3. All types of roof shall be insr_:ed prior to any roof being installed 4. In order to re^_oive a final, you must complex ceps 1, 2, and 3. I,) Preinscecdon or tear off approval. 2.) In progress in_�ec ion approval. 3.) Final insoec.ion approval. a.) Operable smoke detector ve ification • b.) Spark arrestor installation 3. If plyvvecd is installed, a plywood nail inspection is required. 6. If any roof is applied without firs: obtaining an inspection, you will be required to remove all new trate ial down to the sheathing and a building -c inector vviil inspect all sheathing at that time. NVE UNDERSTAND Ta'B ABOVE POLICY ON RE POLICY NG PND WILL CO�CPLY WITF. Tri POLICY c � EOj�vfEO\WcRSNAbfE: ra- ADDRESS- REROOFING COIv1PANY NA.V1E: -- APPLICMNTS SIGNATiIRE: —� • CITY OF CUPERTINO BUILDING DEPARTZCENT Reroof1%vinw6rd