R-5776 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5776
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 B DAYS FROM LAST CALLED INSPECTION.
�UILDING ADDRESQS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �/�'yy� Q HAZARDOUS FIRE AREA
NAME / x' - ' ' `� —� YES ❑ roof assembly s required.hatt a Class A
NO ❑ Initial I.C.B.O.N
ADDRESS / EXISTING ROOF COVERING
'7
PHONE 9 l b /0 9 0 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
— TO BE REMO TO BE RETAINED
NAME S
ADDRESS / � p.. TV �'ROO OVERING
CITY&ZIF✓O 1, x t.�r - L7502-3 //
<// p\\ EXI TIN
,11
PHONE `�O I&o�2 - 8 23 3 BUILT-UP ROOF
LICENSE 3 .513 ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. / WOOD SHINGLES El
License Cies Lic.Num at —5`
Date O Contractor OTHER(SPECIFY) ❑
OWNER-BUIL DERDECLARATI N PROPOSED
I hereby affirm that I em 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 Q a
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF "Q I/��zt
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions /Q
of the Contractor's License Law(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 PO `t'(l V,
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).):
❑I,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-
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.II,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 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 contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&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: /�
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, / Building
as provided for by Section 3700 a1 the Labor Code,for the performance of the work for which this g -A
perm. Isieauad �� 9390 / Seismic ! °
have end wlll maintain Workers Compensation Insurance,as required by Section 3700 of
t Labor Code,for the performance of the work for which this permit is issued.My Worker's %
ompen Cation Insurance carrier end Policy number are: Total 00
Carrier y Policy No. PERMIT PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE fill
) ��� _
(This section need not r completed If the permit Is for one permit
I sI dollars hall or less. /�a°1
person
that 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 Lowe o/Cali- All roofs Shal�gg,'lected prior to any roofing material being
fornia. installed. If Y fis-installeultwithout first obtaining an
Date 7Aa 7 d Applicant Z, — inspection,I agree to remove all new materials for inspection.
subjectlio to APPLICANT:
o k rs'Co Compensation n ProvisionsCardiff L borcode,you musufoinwithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I certify that I have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cove�be "or better.hereby authorize representatives of Chia city to enter upon the above-mentionetl property for In- 3'l g!
hereby
purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities.
judgments,costs and expenses which may in any way accrue against said City In eonaequence
• of the granting of this permit. SIGNATUR F 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