R-5278 1
PERMIT
t �^ APPLICATION FOR CITY of CUPERTINO NUMBER R" 5278
I 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 (\ � //
v-/ `-� V " " RESIDENTII COMMERCIAL OTHER
OWNER$ HAZARDOUS FIRE AREA
WVES ❑ If yes s I understand thatClass A
NAME ^ _ root assembly is required.
S O ❑ Initial LC B.O.N
ADDRESS / l , �-�-! ( EXISTING ROOF COVERING
PHONEqaQ-) r —1 s I NUMBER OF EXISTING COVERINGS
CONT TO 'S
6(�,I^r.��� (1 ^ TO BE REMOVED TO BE RETAINED
NAME i \lam^ 1
ADDRESS I 1�� �jy A _ TYPE OF ROOF COVERING
CITYaZIPI__ ]D�e �7 )Y� �j — TI
NG
PHONE `! l� \92 �� > - BUILT-UP ROOF .❑
CENSE
NUMBER ASPHALT SHINGLESfy�I��-
LICENSED CONTRACTORS DECLARATION J`
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of DNlslon 3 of the Business and Professions Code,and my license Is In full force and
effect' WOOD SHINGLES ElLicense Clea Lic.Number
Data Contractor OTHER(SPECIFY)
OWNEP,.Bu D-MaPIKTION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reaeo .
(Sac.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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE$b A I D
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to
a civil penalty of not more than live hundred dollars 15500).): WOOD SHAKES
❑1,as owner el the property,or my employees with wages as their sole compensation,will do N �� ���
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
slons Coda:The Contractors License Law does not apply to an owner of property who builds of WOOD SHINGL
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or Improvement j` Y° of V UI-Cfl I I
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPE&
rry
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 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 MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one 01 the following declaration: �?
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided lar by Section 3700 of the Labor Coda,for the performance of the work for which this f/I�12
permit Is issued. �gl`�I I f I/YTq\ �O Seismic
1 have and will maintain Worker's Comps atlon Insurance,ape
required by Section 3700 of 111 I W��
the Labor Code,for the performance of the rk for which This permit Is Iseuetl.My Workers
Cc on Ins re ce car antl Policy nu bar are: �]� '� Total
CIS Pollcy o �11u_ _ 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 less.)
I certify that In the performance of the work for which this permit Is Issued,I shat not emp
any person In an me nor So es to becom ublact to the Workers' r pe f II roofs shall be inspected prior to any roofing mater?51 being
Torr a. _ sEatted. If a roof is installed without first obtaining an
Dale Appuca n inspection,I agree to remove all new materials for inspection.
subjecctt t Tit
Workers'Compensatioafter n Prrovisionls Certificate
Labor Code you must o t wlltlhdc mply 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 application 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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spection purposes.
(We)agree to sada.expenses
and keep harmless ins Clry ai Cupertino against Ilebllltlea. I
judgments,coats end expenses which may in any way accrue against sero Clry In consequence
of the granting of this permit. SI ATI OF APPLICANT DA E
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
O,F FICE COPY