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R-4608 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4608 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 A 5 RQ�. V' .ry T S f�[) RESIDENTIAL � COMMERCIAL OTHER WNER'S HAZARDOUS FIRE AREA x//33 L ie i nJS J �►7 e YES 0 It yes s mbly is req that. Class A roots—I understand n ty is required. NO ❑ Initial I.C.B.O.H ADDRESS Ste`^^ e /}.60✓� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME r ?SEAS �N.Q+��5 TO BE REMOVED TO BE RETAINED ADDRESS �` C �A gyp` T E FROOFCOVERING CITY a ZIP- J. EXISTING . PHONE ✓ • v p 2' BUILT-UP ROOF ❑ LICENSE a NUMBER 3-G 72— ASPHALTSHINGLES ❑ LICENSED CONTRACTORS DECLARATION 1 hereby allon that em Business licensed antler provisions of Chapter 9(commencing with force and WOOD SHAKES 7000)of Division 3 of the Busineae entl Professions Code,0ntl my license is in lull force entl engin. WOOD SHINGLES License Class Lic.Number Date ,i ��' Contractor OTHER(SPECIFY) E]OWNER-BUILDER DECLARATION PROPOSED hereby affirm that I am exempt from the Contractor's License w for the 1 in r on. IS 7031.5,Business and Professions Cotle: Any city or counal 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 lila a signed statement that he is licensed pursuant to the provisions . of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the Business and Prelessions 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 live hundred yellers(h wag I: WOOD SHAKES �(L ❑I,es ownerofthe property,or to employees with wages as their sole compensation.will s- C_ the work,and the structure is not Intended ore not for seta(Sac owner of Business and Profbuilds o- ilers Code:The Contractor's License Law does not apply to an sonar of property who builds or WOOD SHINGLES ❑ Improves thereon,and who does such work himself or through his own employees,Improvement provided that such improvements ars not or ownerffered forsafe.If,ill however,the enof pring os Improv ement Is sold ntbuild ori provyear for Fbicompletion,ofsthe ownerbuiMer will have the burden of proving that he tlitl OTHER(SPECIFY) ❑ not bulla or Improve for purpose of safe.). ❑I,esowner of the property,amexclusively ns Cod Twith licensed comrederLto construct the project owner f pr Business and Professions Code:The Contractor's License Lew does not PROVIDE LC.B.O. REPORT NO. apply to c an owner of properly whobuildst or improves thereon,and who contracts for such protects with a c m exempt licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sac. ,B 8 P.C.for Ihl9 reason Owner Data APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: 8' W a v Ol�i f-1I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building as provided lot by Section 3700 0l the Labor Code,for the performance of the work for which this permit is issued.an OCT 10 19 5 Seismic an ❑ have entl will themaintainrt 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 CAP Compensation Insurance carrier and Policy number are: CI I I Ul- VUYth I NU Total Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE EXEMPTION FROM WORKERS' COMPENSATION N.C.❑ (This section need not be completed of the permit Is for undred dollars(5100)or less.) I certify that in the performance of the work for which p I shaft not employ any person in any manner so as to become subject 10 t a era'Com sation Laws of Cali- All roofs shall be inspected prior to any roofing material being fornia, installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making th Certificate xemph you should become q licant unde a Comply with all non point subject to the Workers'Compensation provisi sof the Leb Code,you act forthwith comply PP P Y with such provisions or this permit shell be tl med revoked. Source regul ns. - Icertitythat;have read this application d state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,antl All roof CO rings to CIES "O"Or tter. 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 SIG ATURE OF AP ICAN DATE of the granting of this permit. PRE-INSPECTION: PLYWOOD: IN- OGRE 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: �V AM PS / QQ'n1 e-TD fJ ADDRESS: / 33 LJ, � REROOFING COMPANY NAME: �� — APPLICANT'S SIGNATURE: CITY OF CUPERTINO BUILDING DEPAR'T'MENT • Reroof/winword i Citti of Cupertino SMOKE DETECTOR CERTIFICATE OF COMPLIANCE I understand and comply with Section 1210-a of the Uniform Building Code. Section 1210-a requires when repairs to a single family dwelling exceed $1,000, a smoke detector will be installed, mounted on the ceiling or wall in each sleeping room and at a point centrally located in the corridor or area giving access to room used for sleeping • purposes. If existing smoke detectors comply, no new detector shall be required. I understand the above requirement and certify that we now have smoke detectors installed that do comply. ADDRESS: PERMIT NUMBER: HOMEOWNERS SIGNATURE: �( DATE: l��q 5 winword/smkdet