R-5519 PER
APPLICATION FOR CITY OF CUPERTINO
NUMBERR' 5 519
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL ` COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
I �- QQ , VES ❑ It yeaI understand that a Class A
NAMEoqN
/7 / ass sembly is required
I.C.B.O.If
ADDRESS �,17� `2 (341&"4419A,Ve. ( " Aae_v'tT`w!1 EXISTING ROOF COVERING
PHONE ,p NUMBER OF EXISTING COVERINGS
CONTRACT R' /J/�-�
TO 8E REMOVED TO BE RETAINED
NAME—
ADDRESS
AMEADDRESS (y�A �.�/ Q,, �' PE F RCOVERING
CIN 8 ZIP/'rl e ,�L�/`ACLS"(/r{//�(G�fe EXISTING
PHONE(��h_7, 9- ,/ BUILT-UP ROOF
LICENSE A
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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 /tom
effect. lJ
WOOD SHINGLES ❑
License Class Llc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 ❑
sopllcant for such permit to file a signed statement that no is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the �r
• Business and Professions Coda)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
a civ0 penalty of not more than five hundred dollars(5500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do W ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees.provided that
such Improvements are not Intended or offered for sale.IL 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 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 does not PROVIDE I.C.B.O.REPORT NO.
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 Sec. ,B&P.C.for this reason
Owner Date APPLI ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury e ono o the following
suref rWo /g
❑ have and will maintain a of the
bof Consent tosell-Insurefor Worker's Compensation hthi; � "I A Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p
permit is issued.
[:jI have and will maintain Worker's Compensation Insurance,as required by Section 37000 /TV Seismic
Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation Insurance Carrier and Policy number are: F 1-u-,
Total
Carrier Policy No. fi AUTHORIZATION/// DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 7N .
(This section need not be completed if the permit is for one hundred dollars )or less.)
I certify Nat In the padormence of the for which this permit is Issue4 hell not employ
any Person in any manner so as m hew a bject to the Worljars'compene ion Lawa of call- All roof.^.sh Inspected prior to any roofing materia being
fornia. I �Ap �7 installed. If a roof is installed without first obtaining an
Date j, ^ Ca � �" inspection,I agree to remove all new materials for inspection.
subiailtot eWorkers'CompeO APPLICANT: nsation provisions of theCertificate
Labor Cape,you must fothwidth Comply Applicant understands and will comply with all non point
with such provisions or this permit shaTbe deemed 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 coverings to be classbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said CityIn consequence $IGN TUBE OF APPL C NT 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
OFFICE COPY
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