R 5602a
OFFICE COPY
NUMB R R- 5602
APPLICATION FOR CITY of CUPERTwo .
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 (AST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
VES ❑ If yeaI understand thatClass A
NAME_ ( GDA Q�
roof assembly Is required..
NO Initial I.C.B.O.If
EXISTING ROOF COVERING
'1 y /�
ADDRESS A¢�.4,7.{S [i l;n)n (ia
PHONE QS '
NUMBER OF EXISTING COVERINGS "
CONTRACTO
TO BE REMOV TO BE RETAINED
NAME
ADDRESS/
TYPE OF ROOF COVERING
` �>
CITV 8 ZIP ! O
1 XISTING
/
6SO
/ '7109—Al
PHONE ! b /q —A l I
BUILT-UP ROOF ❑
LICENSE
NUMBERASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensetl under provisions of Chapter g (commencing with Section
WOOD SHAKES ❑ -
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES El
License Cl a s � Lla Number
Data Contractor
OTHER (SPECIFY)
OWNER -BUILDER DECLARA ON
I hereby affirm that I em exempt from the Contractors License Law for the following re n.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct,eiter,improve,demolish,air any structure, prior its Issuance, also requires the
conlisant for suchpermit tofile a signedstatement that he Is licensed pursuant to the provisions
rovis
BUILT-UP ROOF❑
of the Contractors License Law (Chapter B (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 civil penalty of not more than five hundred dollars ($500f):
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 Profes.
slons Code: The Contractors Umnse law 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
la old within one year of completion, the owner -builder will have the burden of proving that he did
OTHER
not build or improve for purpose of sale.).
(SPECIFY) ❑
❑ I, as owner of the property, em exclusively contracting with licensed contractors t0 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 for such projects
with a contractors) licensed pursuant to the Contractors License Law,
❑ 1 am exempt under Sec. ,B a P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner bate
WORKER'S COMPENSATION DECORATION
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 self -insure for Worker's Compensation,
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as pravided for by Section 3700 of the labor Code, for the performance of the work for which this
BUI ding
parmll Issued.
Workers Insurance, as required Section
have and willfor
�� ANS
R ANSiD
M
/_ �/Y1 Y.•t/
7�
$615mIC }'L
the performance f the work
the Labor Code, for the pedormence 01 the work for which This permit IB Issued. My Worker's
for u Worker's 's
ejJll!
Compensation Insurance carrier and Policy number are: �)ll
Tv
Ut Uut- ' t
Total
Carrier �j'pLQQ1` O t��L Policy Np,
PERMIT AUTHORIZATION
DATE
CE&IPI TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to became subject to the Workers' Compensation Laws of Cali.
fornia,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials forinspection.
subjectmEn TO APPLICANT.It. afterofbecome
Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked.
1
source regulations.
certify that l have read this application and state that the above Information to correctI agree
'
to comply with all city and county ordinances and aisle Iowa relating to building construction, and
All roof coverings to be Clasx" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spectionagreetos.
(We) agree to save. Indemnity and keep harmless the City Cupertino against Ilebllltles,
�• -
/Y �_ -Fe
ai
of tthe granting sts and of this permit which may in any way accrue against said City In consequence
I NATURE OF APPLICANT ATE
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