R-5612 PERMIT R_ 5612
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 ADDRBSSq
22 322 ,
. Li /�- RESIDENTIAL / COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME��-U e- `+ 1 a.cry roof assembly is required.
—� F NO Initial I.C.B.O.N
ADDRESS o ��01of In C14 EXISTING ROOF COVERING
PHONE Z/— //,33 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
/I I I` C___ 7 TO BE REMOVED TO BE RETAINED
NAME �'T ..7Ct'�.CY115 1CGX}riK+� �C
ADDRESS cl U i•
TYPE OF ROOF COVERING
CITYBZIP K1
EXISTING
PHONE `r 7�— /Z�tS� BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
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
affect. WOOD SHINGLES ❑
License Class Lic.Number 3 001
Date e �'-� � contractor to OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. /�
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to �b
construct.alter,improve.demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF �p
applicant for such permit to file a signed statement that he is licensed pursuant to the provislons /
of the Contractor's License Law(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 SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES El
I,as owner of the property,or my employees with wages as their sole compensatlon,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,andwho 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-buildor 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 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,e 8 P.C.for this reason
Owner Dale PLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION P A
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's Comb' yyn��, BDildin�, �
as provided for by Section 3700 of the Labor Code,for the performance of the work forWgs.. C
permit is issued. �sstltltl 0 {�CD �I86,� Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by 3700 of
the Labor Code,for the performance of the work for which this permit is issue y VJnn',4k�nnr'9
Compen�sjj/•9 Lt n Insurance carrier and Policy number are: yr LUt h'rf' Total
carrier K"' "tylt ' �-�+�IE''+nnl`1+/ PolicyNo.ja9.�140/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE PTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed it 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 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any rooting material being
fornia. installed. If a root is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTlCE Os' If,
tlsutltlbecome
subject t.the WorrkerCompensaprovisions of the Labor Code,you must forthwith 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 InfOrmetlon Is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to.4 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree tos save,indemnify and may I h any
a y the City ai Cupertino against li qumi s,
judgments,costs and expenses which may In any way accrue against said City In nnsequence '- tGNAFUF�dPPLICANT 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