R-5407•
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RR- 5407
APPLICATION FOR CITY OF CUPERTINO NUMB
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
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RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
0,
YES E] If yes — I understand that a Class A
NAME ( �L. r�1.L�
roof assembly is required.
NO Initial I.C.B.O. N
r
EXISTING ROOF COVERING
ADDRESS rT�—/ 1- o�-� Z- /•t!,?�1.(/ `r(e�JO
�— /� _r
PHONE Q
NUMBER OF EXISTING COVERINGS
CONTRACTORS
`p G
TO BE REMOVED TO BE RETAINED
NAME t &L." %!�j'.
TYPE OF ROOF COVERING
—t� —�M.�+
ADDRESS /� �i/ �.� ��
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CITY & ZIP C/n 9'Q� i ^�`r�ri'�'r'
EXISTING
Lr�^�c
%'%9' Ol%�
PHONE �l� 6 l
BUILT -UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES C /
Y
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES El
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect' p
WOOD SHINGLES ❑
JS/License Class Lic. Number , `'
OTHER (SPECIFY) El
Date Contractor
OWNER - BUILDER DECLARATION
PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following r n.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repairany structure, prior to Its Issuance, also requires the
BUILT -UP ROOF ❑ '
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions 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 o permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500)0:
WOOD SHAKES ❑
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Profes-
sionsCode: The Cant ' actor's
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. It, however, the building or improvement
Is sold within one year of completion, the owner - builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not 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 prolece
with a contractors) licensed pursuant to the Contractor's License Law. P
A FOOVIDE MFGR. INSTALLATION SPECS.
C] I am exempt under Sec. ,B 8 P. C. for this reason(/
Owner Date
p TION DATE
VALUATION
PERMIT FE
WORKER'S COMPENSATION DECLARATION P
I hereby affirm under penalty of per(ury one of the following declaration: //����i.
1 have Certificate Consent insure for Worker's Conno
❑ and will maintain a of to self- al%(��1
as provided for by Section 3700 of the Labor Code, for the performance of the work for which thigh L
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perms s issued.
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have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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the Labor Code, for the performance of the work for which this permit is issued. My Worker's
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Compensaati'o+nInInssuurannce ce[rrlorr entl Policy number are:
Carrier ✓✓� / y Policy No. � �'�7
PERMI UTHORIZATION
TE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed It the permit is for one hundred dollars ($10() or 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 Cell.
All roof:'. I be Inspected prior t0 Any roofing material being
fornia.
installed f a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, you should become
Applicant understan and will comply with all non point
pP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
'
with such provisions or this permit shalrbe deemed revoked.
Source regal join
I certify that I have read this application and state that the above Information is correct. I agree
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to comply with all city and county ordinances and state laws relating to building construction, and
All. Of C SS or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for in.
spection purposes.
O
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City in consequence
IG RE FlAPPLICANT DATE "
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY