R-5375it
OFFICE COPY
PERMIT R_
5375
APPLICATION FOR CITY OF CUPERTINO . NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (409) 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
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HAZARDOUS FIRE AREA
YES Ilyea —Imbly squire aClass A
NAME! 10i6F I-C—lI {r7 SC `rTY{
f assembly is requiretl.
is
NO ❑ In C.B.O. k
� ��% UG^"
� - .EXISTING ROOF COVERING
ADDRESS —'
NUMBER OF EXISTING COVERINGS I
L 60 1
PHONE
I
TO BE REMOVED TO BE RETAINED
CONTRACTOp'$�s� '
/7r§ 1liKf�l
TYPE OF ROOF COVERING
EXISTING
NAME r _
ADDRESS y�0 , t6 I ,,.I�
CITY & ZIP `•V �C.� �J�
PHONE
BUILT -UP ROOF El .
LICENSE L 9 I
Al
NUMBER 7 / d
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES ❑
7000) of DI Ion 3 of the Business and Professions Code, nd my license Is In futi force and
effect, �/+}]
4
-
WOOD SHINGLES
License Cl ea Lie, Number I
OTHER (SPECIFY) `7 ❑
Date
CBIJILDor
PROPOSED
N DECLARATION
\OWNER
the
hereby aifBu Ines em exempt from the Contractor's or roue Lew for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which quires a permit to
construct, alter, Improve, tlemolleh, or r�palr any structure, prior to Its once, also requires the
BUILT -UP ROOF �/
applicant for such permit to file a signed statement that he Is Ilcan pureuant to the provisions
of the Contractor's License Law (Chapter 9 (cofmLiending wit ctlon 7000) of Division 3 of the
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Business and Professions Code) or that ha la axe t th rom and the basis for the alleged
exemption. Any violation of Section 7031.5 by any app t for a permit subjects the applicant to
net more than five hundred dollars,($500 -
ASPHALT SHINGLES
e civil penalty of .
❑I, as owner of the property, or my emplo with wages as Ir sole compensation, will do
WOOD SHAKES
the work, and the structure Is not handet�.o of for sale (Sec. 44, Business and Press -
sions Code: The Contractor's License Law does not apply to an owner ropety who builds or
Improvise thereon, and who does sufhSvork himself or through his own emp ees, provided that
WOOD SHINGLES ❑
such Improvements are not Intentlad or offered for sale. If, howeveq the buildln r Improvement
is sold within one year of comgleflan,the owner- bulider will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for pur se of sale.).
❑ I, as Owner of the poperty, 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 owns property who builds or improves thereon, and who contracts for such projects
with a contra gs)licenaed pursuant to me Contractor's ucenae Lew.
PROVIDE MFGR, INSTALLATION SPECS.
❑ 1 a xempt under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of ury one of the loll�ging shadow
P p
❑ I have and will maintain a Cartilicat of self- Insure for Worker's Compensation,
as provided for by Section 3700 of the L ode, arthe"ponermance of the work for which this
P'1
EL )
�p IY•/,
BUlldl
permit Is Issuetl.
❑ I have antl will mein�te�n orker'e Compensation Insurance, es required by Section 3700 of
Ci
I
.SeISIn ic
the Labor Code, for �padormence of the work for which this permit is Issued. My Workers
Compensation I prance carrier and Policy number are:
��� y 1 `
Total
Carrier Policy No.
PERMITillTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed if the permit Is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit is asu 1 shall not employ
any person In any manner so as to become su t to the Workers' cam ns un Laws of call-
All roofs shall be inspected prior to any roofing rr rial being
fornia.
13 -9
installed. If a roof is installed without first obtaining an
Date 0- Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
subject lI.EtheOWorkera'C mpofnsati n prrovisions of Cortificatoof
Code, Exemption, ou mustuforthwith bcomply
with such provisions or this permit shalrbe deemed revoked,
SOUfCe regulations.
I certify that l 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-r of coverings to be ss "C "orb Her.
hereby authorize representatives of this city to enter upon the above - mentioned property for In.
sPe(We) Purposes.
_ 13-�7
I ��,
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
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judgments, costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
NATURE 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