R-5271 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 5271
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
Ca,
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"4, (� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME of assembly is required.
c NO Initial I.C.B.O.If
ADDRESS vim— EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR' '
NAME — aM. TO BE REMOVED / TO BE RETAINED
ADDRESSAMU C� _ TYPE OF ROOF COVERING
clTv a zip
/ 7005 Vl 1 err' EXISTING
PHONE ��6, 9 9 r+ Z BUILT-UP ROOF x.\10 •% ❑
CENSE
NUMBER Z/bSj IT ASPHALTSHINGLnES r ��i 9
LICENSED CONTRACTORS DECLARATION ``V . 1,
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKEgQ JAL
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and V
effect. 3 9 (, / WOOD SHINGLESti
Date 4,JC ElLicense Class Lic.Number
,Z 7 OTHER(SPECIFY) E] �j
Contractor
OWNEECI-ARATICAPROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law far the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
constructatter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ G
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business end Professions Code)or that he le exempt therefrom end the beefs 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).):
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
Improve
thereon,and who 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 ownerbunder will have the burden of proving that he did OTHER(SPECIFY) AL
not build or Improve for purpose of sale.).
0 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. 6;2o-_3
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a c(ntractons)licensed pursuant to the Contractors License Levi. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B B P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Worker's Compensation, On BUlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit1 r/p 7 Seismic
/
Issued. /a / �� (� 0
revs and will maintain Workers Compensation Insurance,as required by Section 3700 0l
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
'Compen if Inl3ura�ca carrier and Policy puumber are: (� Total
Carrier u1n � Policy No.t"I 1 q� ��' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.GI]
(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 shall not employ
any person In any manner so as to become subject to the Workors'Compensation Laws o1 Cali. All roofn s II a inspected prior to any r Ping aterla eing
fornia. 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: It,alter making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P Y with all non point
with such provisions or this permit shalObe deemed revoked, source regulations.
I certify that I have reed 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 coverin /.4�be class
l"C"or better.
hereby above-mentioned
y authorize representatives at this city to enter upon lite property for In. � M`/�lA� Z/ 4
spection purposes. 1[K/
(We)agree to save,indemnify and keep harmless the City of Cupertino against Iiabllltles,
judgments,costa and expenses which may In any way accrue against said City in consequence SIGNATURE APPLICANT ATE
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