R 5024 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB R R- 5024
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• Ir IN
WITH180 DAYS OF PERMIT ISSUANCE OR
WI IN 1 FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7 5/V 6164(IV) LIC il C- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 VES ❑ If as—I understand that a Class A
NAME S i/ h 4 Z t 1 roof assembly is required.
[� rr L NO ❑ Initial I.C.B.O.It
ADDRESS'/ !w �3Ar h {4G (' F EXISTING ROOF CQVERING
PHONE Z 2 O pNUMBER OF EXISTING COVERINGS
CONTRACTOR'S 2 TO BE REMOVED J TO BE RETAINED
NAME� C+ C I s� f-e—k
1 ADDRESS ��/ �L�.o 2i0 S Dr �� H 3,�f TYPE OF ROOF COVERING
J. CITYBZIP I
5SfZIEXISTING
PHONE Vnt� o i e` Sf 91 5 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 0(commencing with SeMlon WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Cleag. Up.Number
Date ContractorOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031,5,Business and Professions Code; Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any 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
' at the Contractor's License Law(Chapter g(c enpping with Section 7000)of Division 3 of the
Business and Professions Code)or that he I efnpt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by an p 11 n for a permit subjects the applicant to
e dull penalty of not more than five hu he tlole 5509).): WOOD SHAKES
❑I,eaownerol th erty,or mye a It ages as their sole compensation,will do
the work,antl ins et cWre lanbt Into tl sd'for sale(Sec.7044,Business and Profae-
alone Cotle:The C recede LIc as at apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,an ho e u orK ImeeIf or through his own employees,provided that ❑
such ImpravemeMtrar In alo(offered for sale,If,however,the building or Improvement
Is sold wllhln one yeeryt_c pledon,the owner-builder will have the burden of proving that he tlld OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
O 1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, p Buildin O
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ® py, g �
permit Is Issued.
[D seismic ��
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's p O
•'1+. Compeneetlon In ce carrier and Policy number are: ZKS�9 ♦ �117°,�� 30/ �QWO ' Total
Carrier Policy No. b ` PER ITAtHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be complaled If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit is Issued,I shell not employ
any person In any manner o as to become subject to the Workers'Compeneetlon Laws of Cell. All roofs shall be Inspected prior to any roofing m erla be-Mg
f°`nia. installed. If a roof is installed without first o taining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO ecome
subject to the Workers'Compnation proafter visions of the iLabor Code,cate of you mustforthwith lbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have read this sppllcailon 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 rO coverings to ossa 'Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllitlee,
jutl manta,caste end%peneas which may In any way accrue against said City In consequence
of iRe er 11`og of this permit. SIGNA E OF APPLICANT DA
' 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