R 5644 -r PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 �^
/O �� /` RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZA RDOUS FIRE REA
t
,,,, YES ❑ If yes—I understand that a Class A
NAME�6�e root assembly is required.
NO ❑ Initial I.C.B.O.u
ADDRESSpj1'yvz—^ EXISTING ROOF COVERING
PHONE �d O 7 & ` 10 o NUMBER OF EXISTING COVERINGS /
CONTRAC S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS '5QTYPE OF ROOF COVERING
CIN B ZIP
`��3_6 3-73 g +3d EXISTINGPHON '' II o BUILT-UP ROOFLICENSE
❑ /
NUMBER `'G p 200 ASPHALT SHINGLES ❑ Y/
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES /yC�-I 7007000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES F-1
License Class Llc.Number
Date S 2 contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARA ON PROPOSED
I hereby affirm that I em exempt from the Contractor',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,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
of the
tracuch permit a IIIc aChapt rstatement that he Is licensedSection
pursuant to the provisions the P p B 0 O � ^/t
of Ne Conor such License Lew(sneerer (commencing h with Section 7000)of o the
3 of the GW 1J`�
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES r
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($500).): p�/ Q ry fifi n"�
C]1,as owner of the property,or my employees with wage,as their sole compensation,will do WOOD SHAKESDAY NE
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.sionn
s or
improves
Code:The,an who
License Lew tlossnot apply ghhiso an own employers.pho rovide that WOOD SHING118(UF I/U�tnt Ej
Improves thereon,and who doe$such work himself or through eve awn employee$.Improvement that kWJ
such Improvein ments are not Intended or owner-builder
for edea. ill however,the en of pr or Improvement
Is nt ld build oImprove for purpose of stheowner-builderwillhavetheburden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,esnwnerofthepmperty.amexcluslvely contracting with licensed contractors to construct
the project(Sec.7044,Business and Prolsssions Code:The Contractors License Law doe,not PROVIDE I.C.B.O.REPORT NO. QLA2 "Mis—
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractor(,)ilicensed pursuant to the Contractor's License Lew. PROVIDE III INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
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 sell-Insure for Worker's Compensation, /��
t,0 Building _
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ,_ 2 / '
pmts Issued. 2 666 Seismic l /
have entl will malnin)n Worker's Compensation Insurance,es required by Section 3700 01
th Labor Code,for the performance of the work for which this permit is issued.My Workers �r a
Compensation III +ra a carder entl�Plolicy number are: �^ Total 16
Carrier �'• � — PolicyNarS7L`17 /� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed It 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,16 not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of calf. All roofs shall be inspected prior to ny roofing material being
forma' installed. If a roof is installed without first obtaining an
Dare Applicant inspection,I agree to remove all new materials for inspection.
subject to the Workers'CompeE TO APPLICANT: f,after nsation making
ne of thelcate of Labor Code,Exemption,
must forthwlitthbecome
comply Applicant understands and will comply 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 state that the above information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction,and All roof coverings to be class"C"or better.
herebyauthorize purposes,representatives of this city to enter upon the above-mentioned property for In. ,{n( /1 .1 y
sP(We) Purposes. J ,\/�7Yh//I1 /r���9p
(We)agree a save,indemnify and keep harmless the City of Cupertino against Ilebllltlss, ff
of the gran conte and expenses which may In any way accrue epalnet said Clry In consequence
of the granting of tela permit. SIGNATURE OF APPLICANT DATE
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