R-5560 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
5560_]
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM IAST CALLED INSPECTION.
BUILDING ADDRESS
0 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME �FQQ Y J�� YES ❑ It yeas assembly
is required. Class A
_ roof as5embty is required.
�A NO ❑ Initial I.C.B.O.N
ADDRESS --+1'��J AE 4's a-bD✓( EXISTING ROOF COVERING
PHONE' b�Frr NUMBER OF EXISTING COVERINGS t
CONTRACTOR'S �� ��
NAME Q'(— C TO BE REMOVED TO BE RETAINED
ADDRESS SN Sd �S TYPE OF ROOF COVERING
CITY&ZZI�I-P 1/ Sr EXISTING
PHON?` D a � -��og BUILT-UP ROOF. ❑
NIUMBER CENSE ASPHALT SHINGLES
'LICENSED CONTRACTORS DECLARATION
I hereby affirm that i em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000) of the Business end Pro ,and my license Is In full force and
of Division 3 Professions Cade
effect. C-3!7 - � WOOD SHINGLES ❑
License Claes�G'�_ LIc.Number `
Date —�Z-' Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires e permit to �� r?
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Q
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 0(commencing with Section 7000)of Division 3 of the AUG13 �UrD
• 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 a permit subjects the applicant to V l{77
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES n
❑I,as owner of the property,or my employees with wages as their sole compensation,will do CII Ur vV`�C15IIIVV
the work,and the structure Is not intended or offered for sale Sec.7044,Business and Profes-
alone Code: The Contractor's License Law does not apply to an owner of property who builds or 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.If,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 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
-71 em exempt 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 perjury one of the following declaration: 9 q 76.s9
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Companeetion, /J / Building
as provided for by Section 3700 of the Labor Code,for the performance of thew.rk for which ihl9 J 1 {{^^
permit Is Issued. 2 loco Seismic
-11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / 7_ 9
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
a�tiCompens `I9su�ra7nce 1carrier a Policy number are: Total
Carrier �f� �9,4b Policy No. l iglWe _5Y7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.) '-Dog A ^ V
I certify that In the performance of the work Mecor
rmit la Issued,1 shell not employ t
any person m any manner so as o become aus s'compene non Lewaof cell- All roofs shall be inspected prior to any rooting material being
fornia. installed. If a roof Is installed without first obtaining an
Date _�Z_ Applicant inspection,I agree to remove all new materials for inspection.
subject otheBWorrk rs'Compensati n provisioafter ns ofetheicate of Laborr Code,Exemption,
muetuforthwtlhbo ly Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
1 cedlty,that l have read this application and state that the above Information is correct,l 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.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City at Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence SIGNATURE OF APPLICANT '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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY