R 5100 PERMIT R_ 51
APPLICATION FOR CITY of CUPERTINO NUMBER
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 ADDRESS //� /(/�I (A1
) 1/1 / 2 I d'{J�` a�µ J t P ) RESIDENTIAL-COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r r VES ❑ If yes—I understand that a Class A
NAME
1 roof assernMy is required.
NO tniaal I.C.B.O.p
ADDRESS m e- EXISTING ROOF COVERING
PHONE #q6 49(W O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
LBS. �4�� as TO BE REMOVED TO BE RETAINE
ADDRESSPa [� .6 I 2/ / _ _ EXISTING TYPE OF ROOF COVERING
CITU&ZIP 1 �yl�— ` S/
PHONE �S o _ 7—.3'3 BUILT-UP ROOF ❑ —7
NUMBER ASPHALT SHINGLES /
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES .❑
7000)of Dfvlson 3 of the Business and Professions Code,and y license Is In full force and /
effect. WOOD SHINGLES O/J+
License Claes Lie.Number
❑ IS/
N9(SPECIFY)
Date Contractor C'
OWNER-BUILDER DECLARATION PROPOSED
hereby eHirm that am exempt from Co e:Contractorscity License Lew for the fallowing reason.
(Sec.70375,alter,Improve,
and Profedemolish,
or rep Cotle: Any city or county white requires a permit to
consVuct,oruImprove,to file asind statement that
prior toIts issuance,pursuant
requlrea the BUILT-UP ROOF ❑
applicant for such cereal to flaw a signed(Chapter 9(comm tnci he Ish Sectio pursuant to the pro of the
. of sin ss and tPro License Law)orthat a(commencing with om and]000)of Division 3 of the T
exempae and violation of Cede)or that he Is exempt Therefrom and the balls for the applicant
to ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section hundred
by any applicant for a permit subjects the epPlicenT to
e civil penalty of not more than five hundred yeesrs(h wag):
❑I,k,and
er the f(he structure
i not I tendedmy employees with rs ale as(Sec.ir sale7044,compensation,will e- WOOD SHAKES
the work,entl the structure ie not Intended or offered for axle(Sea owner
of Business and Plds of
improsionsves
Code:The Cant rectorses such Lewdoes no orapply through
his
re property whobuildsWOOD SHINGLES
improves(hereon,entl who does such work himself or through his own employees,provided that ❑
such improvements are not Intended or offered for ease.If,however,the building or Improvement
Is 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 wale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contracloes License Lew dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds at Improves thereon,and who contracts for such projects I r
with am
under
See,
to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 6 P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby eHirm under penalty of perjury one of the following declaration: 0n
❑1 have and will maintain a Certificate of Consent to seWinsure for Worker's Compensation, s"' A BUlldl
s as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 4'1 ® LS
Pe m Is leaned. L
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �� q Ov SelsmlC
the or Code,for the conformance of the work for which this permit is Issued.My Worker's ig
Ccmpe(nf�•if I Buren/f!�•cerrlar end Policy number are: �,. ��j��7[ C ^ 7F Total
Cerrierl6 v� PolicyNo.4kLL' .L-G -S `i P NAITJ THO RATIO DATE
CERTIFIC rE OF EXEMPTION FROM WORKERS'
COMPENSATION N.C.
It the x�.ysf7('yv.
(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 Can- All roofs shall be inspected prior to any roofing material being
forme. installed. If a roof 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 q latent understands and will tom
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shall be doomed 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 crags to be class"C"or better.
hereby authorize representatives of this cityto enter upon the above-mentioned property for In.
sp purposes.
(We) `%c/— iy/ �•'C4
(We)agreesave„Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs
end expenseswelch may In any way accrue against said CIN in conaequance
of the granting of thispermit.wrmit.rmu. SIGNATURE OF APPLICANT'" DAT
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