R-5336 PERMIT R_ 5336
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1Be DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS x
9 RESIDENTIAL r ' COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �.—(J to I S OL MGt til. roof assembly Is required. ��++ �
//1� NO Injtial cel I.C.B.O.& Al- 23
ADDRESS oma, I Cazitn2. Ave- EXISTING ROOF COVERING
PHONE
_ NUMBER OF EXISTING COVERINGS dxiia �— I
CONTRACTOR'S -
` TO BE REMOVED e5 I TO BE RETAINED ✓Ly
NAME ho
r ADDRESS t) &09
: /� / TYPE OF ROOF COVERING
CITY B]IP t) /&09 N J I'YI f—y P u I VJ- .
EXISTING
PHONE(y 08) (QQ9 -'a 10o BUILT-UP ROOF ❑
LICENSE
NUMBER C — STf 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
effect (� �,/y3 WOOD SHINGLES
License Class� Lic.Number Cos 7 3 fS y�
Date
x/3// Contractor
9 7 l JrS f-S hort✓Roo�'ct OTHER(SPECIFY)
T
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the e: Anytera License Law for the following reason.
(Sec.construct,
It Business and Professions or res Cotle: Any dry or county which requiresalso a permit to
applicant
suer,ch
Improve,demoto file Signeepakeny menstructure,prior to Its Islicensedsusnce,to
sthe BUILT-UP ROOF �a,❑
applicant far such permit a file a Signed statement that he le licensed pursuant to the provisions 11�y A '
• of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 or the Y"
Business and Professions Coda)or 0311 3e is exempt Therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any lty oviolation tmore
of Section 7031.5 any applicant for a permit subjects the applicant to
a civil penalty of not mare Than floe hundred yellers with
wag.): WOOD SHAKES APR
E)1. , owner of the property,or to employeeswith wagee as their sole compensation,will s.
the work,and the structure is not Intentletl ores not for Bale(Bea owner
of property
and Proles- �.
sione Code The ContractorsLicensesuch Law does not apply toanowner ofproperty who builds or WOOD SHINGLE%I� liUYtt 1INO
Improves thereon,and who does such work himself or through his own employees,provided that Y Ur d
such d within one year
are not Intended orow offered for sale.I(however,the en of prding or Improvement /ee
hot bull orImneye for purpose of
owner-builder will have the burden of proving Net he did OTHER(SPECIFY) r
not build or Improve for purpose of sale.).
O I,as owner of the property,am exclusively contracting with licensed contractors to construct -3
the project(Sec.7064.Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. LIZ tI c(
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&P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, /� BUldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit is IJy�000, Seismic
haveve and entl will maintain Worker's Compensation Insurance,ae required by Section 3700
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensatloer Ecy ber ee:
Total
Carrier SRT;
Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ f
(This section need not be completed If the permit Is for one hundred dollars(3100)or less.)
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 Call. All roofs dhall be inspected prior to any roofing material being
fornia. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and wi with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I cardly that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to bac ss atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectionpurposes. -/
(We)agree to save,indemnity and keep harmless the City of Cupertino agalnst liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF AUPLICANT 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