R 5214-PERMIT
R_ 5214
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 ADDRESS
n�f
CZra e l o"jis jig 0. 152n)/L
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
C Ie �(//� �,,1r�
AI^ V«I4 lu
YES Ifthat Class A
NAME r r1xl.�Y11 I
da
assembly si required
NO Initial I.C.B.O. N
�//�1 1 nn�
O 619(d
EXISTING ROOF COVERING
ADDRESS J�/i�l/i k11Ai 1500
'PHONE IM -11No
NUMBER OF EXISTING COVERINGS /
CONTRA4RGNAME
g/
TO BE REMOVED TO BE RETAINED
ADDRESSrROOF
r
�EXISTING
COVERING
CITYBZIP
Z)9- x107-4t&Q
PHONE
BUILT-UP ROOF ❑
LICENSE �, I t�� CE
NUMBER 1
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I em licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES
7000) of 010olon 3 of the Business and Professions Code, and my license Is In full force and
effect sz4�
40 v
WOOD SHINGLES ❑
License Class ""zl� Lic. Number
D" 4u A,
OTHER (SPECIFY) dib (iy
Data Cont, aor
OWNER-BUILDERD RATION
I hereby affirm that I am exempt from the Contract ' Icanse Law for the following reason,
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF 1:1applicant
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter g (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
e civll penalty of not more than five hundred dollars ($500).):
C-] 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 Proles.
°Ions Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not intended or offered for sale, 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) SlMt, 77CA
not build or Improve for purpose of sale.).
�sr
❑ 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 Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts [Or such projects
with a contractor(e) licensed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P. C. for this reason
OwnerDate
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 selbinsum for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
q41BUlldln g
have
A
Seismic
�� and will maintain Worker's Compensation Insurance, as required by Section p��
ih(Lebor Code, for the for a
`e
11
performance of the work which this permit le iesued. My Workartk/
0
Compensation Insurance carr,)�j and Policy number are: l7l'J
Total
�'L
IT AUTHORIZATION DATE
Carrier�Tl YUP6 Poncy No._I�19&Za(JZ)eUr
CERTIFICATE OF EXEMPTION FROM WORKERS'
rtM
COMPENSATION INSURANCE N.C.I]
be
(This section need not completedIf the permit Is for one hundr Ilare ($100) or 1015
I certify that In the performance of the work for which this parml sued, Ishell npl employ
any person in any manner was to become subject to the Workers ompensation Lapp of call-
fornla'
All roots shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining
an
Date t0'21 _Q% Applicant t
inspection, I agree to remo all new materials for inspection.
NOTICE TO APPLICANT: If, after making This rtlficate of Exemption, you should become
subject to the Workers' Compensation provision of a labor Code, you must forthwith comply
PP ply with all non point
Applicant understand nd will comply
with such provisions or this permit shall be dE d r yoked.
source regUlatIORS.
1 certify that l have read this application end et° at the above Information is correct. I agree
to comply with all city and county ordinances and state laws relating to bonding construction. and
All roofs rings obe class"C"or batt r.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino afainst liabilities,
judgmants, costa and expenses which may In any way accrue against said City n consequence
2,14
SIGNAT OF AP CANT 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
OFFIrF rnP'V