R-5394 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
5394 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS /�•
OSQ RESIDENTIAL y COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEmorn roof assembly is required.
O O NO IROOF
I.C.B.O.A
ADDRESS y}/&=a EXISTING ROOF COVERING
PHONE 11? "' p NUMBER OF EXISTING COVERINGS /
CONTRA f/R� ,
TO BE REMOVED 'er TO BE RETAINED
NAME
ADDRESS 0/i / /1� „f; i� L, /—�j► y,,,, TYPE OF ROOF COVERING
CITYB ZIP �-f l./J4JCJ[.c�.aL V1�C.iUL .
�• ���� EXISTING
LICENSEPHONE /n,, //-- BUILT-UP ROOF E]NUMBER l.!! (_CJ ASPHALT SHINGLES El -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect' WOOD SHINGLES ❑
License Class Llc.Number
Data ContractorLl Ill OTHER (SPECIFY) /
NER BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Code: Any city License Law for re following reason.
cons.70315,Bimprov9 antl Profeolish,or repitany Any ally pr or to It Which requires also a permit t0
construct alter,Improve,to file sigrrepeatanystructure,prior toils Issuance,also requires the BUILT-UP ROOF B D ❑ l/
applicant for such permit to flaw a signed r statement that he Is licensed pursuant to the provisions `
of the Contractors License Lew(Chapter h(commencing with Seaton 7000)of Division 3 of the
• Business end violation of Code)or that he Is exempt antfora and the basis for the applicant
to ASPHALT SHINGLES CD ❑
a civil
more
lhan five 7031.5 any appllcantlorepermit subjects the applicant to 27 O[tf
e civil penalty of not mora then floe hundred employees
(h wag): ',�p (d RL
❑I,as and
structure
moot tmy ended oyellered wagesas(Sec.their sole compensation,snPrills. WOOD SHAIcpo� ❑
the work,antl the structure Is License
Intended or aHeretl for sale apply to n owner
of Business and Proles- HI INU
Bionsve thereon,
The,an who
License Lewdoes elf or
hiso n employers,who rovidedsor WOOD SHIT C!I 8Y Vu ❑
improves thereon,antl who tloensuch workhimselffor or through his own employees,improvement that
such Improvements are not Mended or offered for sale.ill however,the building or iImprovement
Is Said not
or
year of for purposetlomlheowner-balitlwrwill have the burden of proving that he tlltl OTHER(SPECIFY)
nal build for Improve ler property,
of sale.).
❑I,as owner of the property,em exdusNeio contracting with licensed contracture to construct
the project(Sec.7006,Business and Professions Cade:The Contractor's Licensor Law tlgoj not PROVIDE I.C.B.O.REPORT NO. �..r
apply to c contractor(s)
property who builds or Improves thereon,and who contracts for such projects -
withacgntexempt licensed pursuant to me Contractor's license Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for his reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, lO/ Bu i l din
as provload for by Section 3700 of the Labor Code,for the performance of the work for which this `
p lalseaed. �Q�y /� $���"' Seismic
have antl will themaintain Worker's Compensation Insurance,as required I$I by Section 370001
Ih bar Code,for he performance of the work for which this permit is Issued.My Worker's
Com�rip¢tlpn Igse ce c 'er and Poll number ere: 4017 Total
CIS �,�!(J-(( Policy a. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE to
(This section need not be completed If the permit Is for one hundred dollars($100)100)o or mesa.)
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 9e to become subject to the Worker ompensatlon Laws of Cali- All roofs all a inspected prior to any roofing material being
forma, installed. If a roof is installed without first obtaining an
Date[ Appliga _ inspection,I agree to remove all new materials for inspection.
NOTICE TO A PLICANT: h,after making this Cerali tw of Exemption, ou should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the abor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have reed this application and State that the above information Is correct.I agree
to comply with all city and county ordl nances and slate laws relating to building construction,and All rOo cooveerin t eC s ' or betterr../�
herebyauthorizeprpo representatives of this city to anter upon the above-mentioned property for im l/t./� /v�
herebBoeotion pur
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
cine costs and
his permit. SIGNATURE whack may in any way accrue against said City In consequence SIGNATURE OF APPLIC 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY