R-5383 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5383
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / uM/ HAZARDOUS FIRE AREA
VES ❑ If yeas I assembly
i req that a Class A
NAME roof assembly is requiretl.
NO Imhal LC.B.O.H
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS ,
CONTRALTO
Q TO BE REMOVED � TO BE RETAINED
NAME
ADDRESS lg q J /1 /� , _ (�f� TYPE OF ROOF COVERING
Gn a zIP / i�wL(b��it1 UM 4 7 t EXISTING
«08� -0 BUILT-UP�siA
PHONE� /
NBUILT-UP ROOF ❑
LICENSE
UMBER ,� L 6
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 'Q
]000)of Division 3 of the Business and Professions Code,and my license Is in full force and ®�
affect' I^'_ tt�� rr�� 1/,., WOOD SHINGLES T
License Class `-� Lic.Number 6✓ � � � � Z un
Date �6 Contractor OTHER (SPECIFY) 0/ l U ❑
OWNER-BUILDER DECLARATION PROPOSED 0���/YU
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
constapplicant
er,such
improve.demel sh,ora sign dstaepair eny menthatstructure,isprioricense issuance,alsoreprovistns BUILT-UP ROOF i i n
applicant for such permit a La a signed statement that g is Sectio pursuant to the provisions I(,.11///��"'I'llltytyii"..--
' of the Contractor's License Lew(Chapter 9(commencing with Section]000)of Division 3 o the / C /-F /� 119
Business and Professions Code)or that he Is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLE J 16 r7 r -1 I
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than floe hundred yellers(h wag): WOOD SHAKES 7 ❑
❑I,as owner of the property,or to employees with wages as their sole compensation,will d.
the work,and the ontracto is not Intended ores not for sale(Sec.7044,Business and Proles-
sloes Code:The Contractors License Lew does elft apply to an owner of property who provided
t or WOOD SHINGLES
Improves
thereon,and who does such work himself or through his own employees,Improvement that
such Improvements are not intended or owner-builder
for sale. ill however,the en at pr or Ig that he
notsold bull or
year of for purpose of sthe owner-builder will have the burden at 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.J044,Business and Professions Code:The Contractor's License Law 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 Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sea ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION MIT 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 Worker's Compensation, 0-2 B I I
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
par is iaaueIf �yI 'n1 ;//� eISR11C
va end will maintain Worker's Compensation Insurance,as required by Section 3]00 of /O / 1 �Y\1 V '
JhfixLatxir Code,for the performance of the work for which this permit Is Issued.My Worker's Total
mpense�llI IInJ�y�enc arrl and Policy number are: -�G
Carrier�-/� _- " "v Policy No.,2 - -V PERMIT AUTHORIZATION ATE
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 less.)
I certify that In the performance of the work for which this permit is Issued,I shall net employ
any person In any manner so as to become subject to I e W ker Compere a Laws of Can- All roof^she e s tied Prior to any roofing material being
fornix. r installed. If a roof is installed without first obtaining an
Dale lUllApplicant / inspection,I agree to remove all new materials for inspection.
NOTICsubject toEthe OAPOLICANf: If,after Worrkers'Compensation provisions o ehlllic 41,r Code,of Exemption,
oiu must forthwitbecome
h comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. source regulations.
I certify that I have read this application and state that the above information is correct.I agree
to hereby lywith thoriz l dry andese county of this ccs and ter u on the
bove- entionedproperty
and All fOOf CO rin be CIBSS "Or better.
hereby authorize representatives of this city es a enter upon the Bing to benllon construction,property for In.
spectionpurposes. /d ILI p
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, `7
' judgments,casts and expenses which may In any way accrue against said City In consequence SIGNATURE O 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