R-56761�
0
OFFICE COPY
NUMB RR- 5676
APPLICATION FOR CITY OF CUPERTINO
- 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
�.%.
el
a ` y
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
(Y� `n p
YES ❑ If yes — I understand that a Class A
NAME I ' ` r ✓ �N e
roof assembly is required:
NO Initial I.C.B.O. M
y/2 61t/ Z
4-
EXISTING ROOF
ADDRESS 2 � , -fifil A
COVERING
C
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/\ (��j
W
TO BE REMOVED / TO BE RETAINED
NAME I �+ G l
TYPE OF ROOF COVERING
cj, zl 2 y c, 2 Q%` -f t� / . ,n/
clrvazlP / J
EXISTING
S'/�/V so Sc m- qs-y� �
PHONE i'o Sr 9 7 -63 73
BUILT-UP ROOF ❑ 7 -
LICENSE
N UMBER ( ,3 S"�
1,-7,
ASPHALT SHINGLES 1:1 1,-7,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
3 i 83r
WOOD SHINGLES ❑
License Class Lic. Number
d
OTHER (SPECIFY) E]OWNER-
DateCtar
BUILBUIUDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the License Law for the following reason.
Code: Any city or county which requires permit to
(Sec. 70315, Business and e: Any city
demolish, or rep prior to its Issuance, requiresthe
a
conable asigned
BUILT-UP ROOF ❑
rsuantalso
ant for such permit 10 fila a signed statement ns
Icandfor suimprove, to file staair tny ement that he Is licensed pursuant to the provisions
of the
of the nci
License Law (Chapter B (commencing with Section 7000) of Division 3 0l the
Business and Code) or that he is exempt therefrom and the basis for the
and
ASPHALT SHINGLES
ptio on of Section 7031.5 by any applicant for a permit subjects the appllcent to
ex to
exemption. Anyviolationo
violation of applicant
t bundredy
a civil penalty of not more thanpert fivedollayees
(h
WOOD
or w
I, as owner of the property, or employees
employees with wages as their sola Compensation, will do
wage:
.SHAKES ❑
the work, and the structure Is not intended or offered for sale Business and Proles-
to
sions The Conwhodessuchwawdoes n owner of property builds or
WOOD SHINGLES ❑
improvsth: wiforthroughnsownefes,proidethat
improves thereon, and who does such work himself or through his awn employees,
such Improvements however, the building or improvement
are not orow offered for sale. improvement
is year leb n,
completion,owner -builder will have the burden of proving that he tlld
ill
OTHER (SPECIFY) ❑
notsold bull or prove for purpose of
not build or improve for purpose of eels.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Convector's License Law tloes not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractions), licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
O 1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPLI A ATE
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 Worker'. Compensation,
��
Buildin6
as provided for by Section 3700 of the Labor Code, for the performance of the work for which,his
permit Is Issued.
I
❑ 1 have and will maintain Worker'. Compensation Insurance, as required by Section 3700 of7x
Seismic L►b
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's b
Compensation Insurance carrier and Policy number are:
I
ul LUr[rttl
l(,g
Total
.�B
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.o
(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 Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject to the Workers' Compensation Laws of call.
fornia.
installed. If a roof is installed without first obtaining an
0. to O !'7 Applicant �:.
�
inspection, I agree to remove all new materials for inspection.
of Exemption,
NO'Ito provisions
Applicant understands and will comply with all non point
of thatcate
subject theOWorkersCC Compensation Labor Code, olu must bdhwlltlthbecome
comply
with such provisions or this permit shall be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spactlon 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 Clry In consequence
�SIGNATU E OF APPLICANT TATE y�
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY