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R 4618 (2) PERMIT R_ 4 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)77,7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRE& RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ If yes—I understandss that a Claw A NAME G'�� ,� �lg!/rl G roof assembly is required. NO Initial I.C.B.O.q ADDRESS— P EXISTING ROOF COVERING PHONE — NUMBER OF EXISTING COVERINGS —l CONTRACTOR'S NAME S.a /& ( q !��/T? 'F - TO BE REMOVED 70 BE RETAINED ADDRESS TYPE OF ROOF COVERING CITYazIP / ` Z-:..i�/.tt .P 9L EXISTING PHONE a2 BUILT-UP ROOF Q/ - LICENSE NUMBER m "— ASPHALT SHINGLES ❑ /� LICENSEDdunderCONTRACTORSsof Chapter 9(N m /�� hereby affirm that emusi nes under erosions of Chapter g(commencing with Section WOOD SHAKES Vd� 7000)of Division 3 of the Business and Professions Code,and my license is In lull torte and ' affect. WOOD SHINGL"ES4 g �>S 1:1License Class Lic.Number �'��r S— v p ,-- OTHER(SPECIFY) al 995 ❑ Date ��--/ Contractor • OWNER the Conn DE L License PROPOSED 1 hereby affirm that em exempt from the Contractor's License Law which chthe Ionsfollowingreason. (Sec.70315,Business and demolish, rep Code: Any city or county which requires a permit to n VurCH I INO construct,alter.Improve,demela sign anyatStructure,prior lolls issuance,also the 1 tO �r ❑ • applicantfor tractor'parente file(signedr9(comincing is licensed ctio pursuanttole provisions BUILT-UP ROOF of the Contractor's License Law)or that h(commencing with therefrom and 7000)of for the ale the LY Business and violation of Code)or that ala exempt ant for end the sale for the alleged ASPHALT SHINGLES exemption.Anyviolationnot onof Section 7031.5byany applicant fora permit subjects the applicant to e civil penalty of not more then five hundred dollars($800),I: CI 1,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 Praise. Slone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sale.II,however,Me building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for This reason Omer Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: El I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, `1s/`tr as provided for by Section 37000/the Labor Code,for the performance of the work for which this qxr� 11WBuilding permit is Issued. (/✓� — SeiBmjD ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of /�� 5 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 Carrier �C 2.2�/ Policy No.y✓wr..7�1 Sir CERTIFICATE OF EXEMPTION FROM WORKERS' - I PERMIT AUTHORIZATI DATE COMPENSATION INSURANCE N.CQ ipii,� xC (This section need not be completed If the permit Is for one hundred dollars($100)or less.) 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 Yorkers'Compensation Laws of Calf All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICsubject to the a WorkersTO 'Compensation tion after provisioniso the laborr cExemption, de y Iu mustuforthwlithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. Source regulations. I certify that I have read this application and elate 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 above-mentioned property for in. epectlon(We)purposes, . (We)agree to Save,ments,costs and expenses and may i harmless was the Clry of Cupertino against liabilities, of the granting of this permit ea which may in any way accrue against este Ciry In onaequence SIGNATURE PPLICANT 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 THE CITY OF CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PERMIT AND INSPECTION PHASE. 1. Prior to permit issuance, you must agree to comply with 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. 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 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 THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE POLICY HOMEOWNERS NAME: ADDRESS: REROOFING COMPANYNAME: 4 <z /�dITD� APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPARTMENT Rerooftwinword