R-5652 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5652
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 ADD/DRESS �Ji Z �� R.
pd, �-/5 RESIDENTIAL —COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
Z/Jz �/r3 NO ❑ Initial I.C.B.O.a
ADDRESS �` y� 4 S -fZ� EXISTING ROOF COVERING
J^
f PHONE ', — /Viz/ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S A /
TO BE REMOVED---/-TO BE RETAINED
NAMEADDRESS
aTYPE OF ROOF COVERING
CITY BZP ��I; t.4 •, LdJ �ToS `h10.�o
EXISTING
PHONE 724 /�YXf BUILT-UP ROOF ❑
LICENSE
NUMBER 7Z7.T91r ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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
anent. Number(1`1 3f WOOD SHINGLES
Lic.
License Class 7e7�9
SPECIFY
Data �'" y -�7 contractor OTHER� � ' '�<• (SPECIFY) /
OWNER-theLDERDEC*sLice ON
se PROPOSED 6 YL
hereby affirm that I am exempt from the e: Any
License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,a signed
or repeat any structure,pylar to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit a file a signed statement that g it licensed pursuant to the provisions /
of the ss and
License Law(Chapter 9(commencing with Section]000)of Division 3 of the
' Business entl violation of Code)or thet he Is exempt infer a and the basis forhe ape alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant far a permit subjects the applicant to
e dull penalty of not more than five hundred dollars with
wage WOOD SHAKES❑I,as owner of the property,t I to dedemployees with wages as their sole Compensation,will do ❑
the work,and the structure Is not Intended ores not for sale(Sec.7044,Business entl Proles-
alone Code:thereon,
Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves o e men,and who does such work elfin or through his own employees,Improvement etl that
such Improvements are not Intended or offered for safe.ill however,the en of pr of Improvement
Is notsold bull or
year of for purpose of
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(Sec.7044,Business and Professions Code:The Contractor's License Law tloes not PROVIDE I.C.B.O.REPSBLNO.
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 Seo. ,B 8 P.C.for this reason
Owner oats A yPFj Lf TION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 I hereby affirm under penalty of perjury one of the following declaration: /1,"7
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, I Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this tV �n
perms la d. �� // / Seismic �•
/ eve and will maintain Worker's Compensation Insurance,as required by Section 3700 6 �/
the Labor Cotle,for the performance of the work for which this permit Is Issued.MyWorke'as�' f Urn / Total
CompensatioAn.Insurance carrier and Policy number are: `/-� -..-_—_ L
Carrier `�7$Tt A-AIP Policy No'", !v" '9G PERM T AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE l00)o
(This oste ($100)or need not be completed It the permit la for one hundred dollars r lees.)
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 Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Delp L�t�' GJ Applicant < S ✓ inspection,I agree to remove all new materials for inspection.
subecct tooETO th Workers' 11,after
making
of�e111Labor Code Exemption,
must foMwfl�hbomply ecome Applicant understands and will co 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 stale that the above information Is correct.I agree
to comply with all city and county ordinances and state laws totaling to building construction,and At r ss"C"or better.
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 against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS: Il,
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