R-5670 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NU BER R- 5670
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDDRREE.SSS�`�yJ
RESIDENi COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
/ YES ❑ If yes—I understand that a Class A
NAME A,:,� SeiZ roof assembly is required.
,// NO ❑ Initial I.C.B.O.ft
ADDRESS— oy� a--,l Cli%C. EXISTING ROOF COVERING
PHONE Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVEDy TO BE RETAINED
AuoaeSs 7 TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE a;vo — .9y>off 0 BUILT-UP ROOF ❑
CENSE
NIUMBER / ASPHALT SHINGLES E]LI ENSED ONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Divlslon 3 of the Business end Professions Code,and my license Is In lull force and
elle`"' 3� \ WOOD SHINGLES
License Class Lit.Number � nq./ lI v/
9—3 _ 9� OTHER(SPECIFY) y
Date 9 CoIJIUDEntract
OWNER-the Contractor's
DECLARATION PROPOSED
hereby affirm Bu that am exempt from the Contractor's License Lew for the requires
aB reason.
(Sec.7031.5,Business and demolish,
or rep Code: Any city or county which requires a permit to P r�
construct,alter, h improve, a signed statement
air eny mentrthat e,Is livenor to rts ed pursnce,uant also to
sthe BUILT-UP ROOF P' H � ❑
applicant for such permit to Ille'a signed statement that he Is licensed pursuant to the provisions
•
at the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 0l the
Business and Professions Code)or that he la exempt therefrom and the basis for the alleged ASPHALT$HINGL6&� G 5 n�([�j'D
�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to JUId
a civil penalty of not more than live hundred dollars($500).):
❑ WOOD SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Protea- CII Y Vr V V rCil j f 4V
alone Cade:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES Ela
Improves thereon.and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for agile.If,however,the building or Improvement
a 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(Sac.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner at property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
Pe
mit la lssuatl. l (/ Seismic
thave
and will maintain Workers Compensation insurance,as required by Section 3700 of p 9
the abor Cotle,for the performance of the work for which this permit Is Issued.My Worker's TOtaI/!
Compensation Insure`ce carrier end Policy n ber are:
Carrier 5�5i! /=uti.� Policy No.�� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE N.C.0 y '
(This section need not be completed It the permit Is for one hundred dollars(5100)or lees.) L AVs e-- S
I certify that In the performance of the work for which this permit la Issued,I shall not employ
any portion in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roc ing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject lot eAPPLICANT.
ow raCCompensation proivsioonls OClet eI abor Cooof de yyodum suforthwltlhbomply 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 Breed 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 coverin to be class"C"or tter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. It
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City Inconsequence SIG ATUREZAPPLICYR7 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY