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R-4080 (2) PERMIT R_ 4080 APPLICATION FOR CITY of CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING AADDRRESS- ` S ��,, BUILDING USE O" /I �DD �e�-- — - RESIDENTIAL�/- COMMERCIAL OTHER OWNER'S ir ///! HAZARDOUS <J ��+' ROOF NAME FIRE >�Jv COVERING AREA CLASS ADDRESS � R� EXISTING ROOF COVERING PHONE 3 S 6 - G NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME_2TYPE OF ROOF COVERING p p i CITY&ZIP � L O 41L1rJ EXISTING rS / 0 PHONE��Z � 7 4 L — 74. Y f BUILT-UP ROOF LICENSE ASPHALT SHINGLES NUMBER Zl /� 9/ WOOD SHAKES LI LENSED CONTRACTORS DECLARATION I hereby affirm that 1 em licensednder provisions of Chapter 9(common ing With Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES me my license is I 1 fly,,.and effect. License !_. ._� Lice Number �� ^ Da. A p Cpnf.xro. •-tpj OTHER (SPECIFY) OWNER-BUILDER DECLARATION' I hereby affirthat 1 am exempt from the Contractor's License Law for the following reasm on. (Sac. 7001.6, Business and Professions Code: Any city PROPOSED or County which requires a permit to construct, alter, improve, demolish,o, repair any structure, prior to its issuance,also requires the applicant for such BUILT-UP ROOF permit to file a signed statement that he is licensee pursuant to the provisions o1 the Contractor's License Lew (Chapter 9 (commencing with Section 7000) pC from' mivind 0 er the Business and alleged exem code)or mss of is exempt thorn ASPHALT SHING4�t&. - 6 905'5 - tom and the anis for the arlermi exemption. Any violation of Sendero 7001.6 by any applicant favhufor a permit subjects the applicant t0 a civil pen•Iry of not more sun live the pr tl dollars($500).): my e.1: WOOD SHAKES ❑ I,as owner of the work, a or he employees nwith wands of[noir free L y for I*(Sec. will do thesin work, entl fM structureode is not intended or offered rl.ES cal LUrt for ale(Sec. 7044, 1.ane..and Professions Code: TMContractor's License WOOD SHINGLES Low eon not apply to an owner of property who builds or ims,rves thereon, (RW and who does such work himself or through his own employees,Provided that N such improvements am not intended or offered for sole. If, however, me OTHER (SPECIFY) building o, improvement is sold within one year of completion, the owner. L. builtlor will have [M burden of proving[M1a[he did not build or improve for purpose ofsale.). PROVIDE I.C.B.O. REPORT NO. ❑ I, as owner of the property, am exclusively contracting with ficenfed Contractors to construct the project (Sec. 7044, Business and Professions Code: TneContractor's �cemeLawdoesnotapplytoanownerofproperty PROVIDE MFGR. INSTALLATION SPECS. whobuilds or improves thereon, and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. C3rn I am exempt coder se<. ,e. P.c.fes.this reason APPLICATION DATE VALUATION PERMII Owner— Date WORKERS'COMPENSATION DECLARATION Building hereby affirm that I have.certificate of consent to sell insure,or a can titter.of Workers' Compensation Insurance,or en aaHia copy te.aofrtSea /G� O� �/ vyv, SBISmic ]800.Lab. .f,��y�� 9 G 7 / ✓(/ Policy No.a�eCrmpany� c ��, T+(Cortified copy is hereby fur .,had. n Total 0 Certiree cop9; d wit acttyctioryd�isio ADpliunt .O irk CERTIFICkrE OF EXEMPTIO FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This section need not be completed it the permit is for one hundred dol. A's 11 DO) or less.) 1 Certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the W.,=s Compensation Laws of California. Dara Applicant NOTICE TO APPLICANT: 11, alter making this Certificate of Exemption. you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being shall be deemed revoked. I certify tet I M1ava reed thisJpplicetion.m+tae tat m..nova inform.. installed. If a roof is installed without first obtaining an ,,an is qo„wt. 1 .gree to comply with au city and county orem..de.And Inspection,I agree to remove all new materials for inspection, Bute Issue ..lain, tr building construction, and hereby authorize proem ta0vn or this City LO enter aeon the above-mentioned property for impaction purposes. Q / IWaf ea,ea abilities, udg in t.mniH antl keep M1esmless the in a of Cupertino 3 egalnlf ,aiityi consequence cons and expenses which may in any way•tura. against ,aid City in consequence o1 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 TIJE CITY OF CUPERTINO BUILDING DEPARTMENT PRIOR TO ISSUANCE OF PERivllT AND INSPECTION PHASE. I. Prior to perwit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's Oil reroofing. 2. New roof coverings shall not be applied rvilhout first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall be obtained from the buildiug inspector when the reroofing is completed. 3. All types of roof shall be inspected prior to any roof beiug installed. d, 1"order to receive a final,you "lust cmuplele steps 1, 2, and 3. I,) Preinspection or tear orf approval. 2.) In progress inspcclion approval. • 3.) Final inspection approval. a.) Operable smoke detector verification b.) Spark arrestor installation 5. if plywood is installed,a plywood jail inspcclion is required. G. Ir any roof is applied rvilhout first oblainijg a" inspection, you will be required to remove all new material down to the slneallring and a building i"spector will inspect all sheathing at Ural lime. WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITIl THE POLICY o HOMEOWNERS NAME: ADDRESS: REROOFING COMPANY NAME: APPLICANTS SIGNATURE: 1Q — CITY OF CUPERTINO • BUILDING DEPARTMENT Reroof/wimrord