R 5385 APPLICATION FOR CITY OF CUPERTINO
Nu e'ERR- 5385
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT E%PIRES IF WORN IS NOT STARTED
WITHIN 1B0 DAVS OF PERMIT ISSUANCE OR
1B0 DAYS fROM LAST CALLEO INSPECiION.
� BUIL�ING ADORESS '
ul./v C�• ��S GfC/l� RESIDEMIAL COMMERCIAL OTHER
OWNER'S ` , � AZARDOUS FIRE AREA
. NAME � �(J VES ❑ If yes-I undereWnd�het a Gass A� �
roof assembty is required.
' � NO 7 IniHel I.C.B.O.p
nooResS EXISTING ROOF COVERING
PHONE " a ✓�-r � NUMBER OF E%ISTING COVERINGS _ Z
CONTRACTO/F�'1� � ,/� �/� (/�,� I (\ �'� � ���"�(.��e+
�NAME \ �1_7� \�' �{J-� �-�""�— `��-%-��1 1� TO BE REMOVED - TO BE RETAWED
ADDRESS 1 ��„O„ TYPEOFROOFCOVERINGL�
CITV&ZIP �� � ' '
]'� EXISTING
PHONE � `� BUILT-UPROOF ❑ .���
LICENSE p ` / �
NUMBER p o�Q ' � ASPHALTSHINGLES � �
UCENSED CONTRACTOflS DECLARATION
I hereby ellirm�hat I em licenaed under Droviaians ol Chepter 9(cammencinp with Section WOOD SHAKES �
]000)ol�Ivlelon 3 0��ho Buelnaee and Pmleaelons Cotla,entl my Ilcenae le In lull br<e antl
e��eC1 I .,Rg '�1.� WOOD SHINGLES ❑
Licenea Claas Lic.NumCer�='k '
___�� — OTHER(SPECIFY) ❑
�ete Contrnqar
OWNER�BUILDEROECLARATION pAOPOSED � A
I hemEy eilirm�he�I em exempl�mm�he ComrecmYa License Lew lor�he IOIIowInB�oeaon, f� �
(Sea]031.5,Businass antl Praleealans Cotla: Any ciN or counry which requlrea e permit to � J
conslmct,elter,improve,Eemolish,orrepelranyetmcture,ptlarroltsleauance,elsorequlrealhe BUILT-UPR��F �
epplicanl�or auch permlt to ille e elgne0 stetemenl thet ho le Ilcensetl purauent to ihe provlalona . �
ol t�e Conirecror's Liconae Lew(Chepter 9(commencing wlih Section 700�)of�Ivlalon 3 oi the
� Buslnene entl Profeealann Cotla)or ihat he Ie exem0��hBrairom entl fha besis for�he ellegeE A$PHALT$HINGLE$ -`��,� `
axempllon.Any vlolepon of Sectlan]W 1.5 by any aOP��cent lor e permit pub�eds lha eppllwnt�0
e civll penelry oi not more t�an liva huntlretl tlollare($5W�J: V
❑I,eeownerol�heproperty,ormyemployeaswithwegeeeethelr6olecompeneetlon,wlltdo WOODSHAKES � �
t�e work,end ihe s�mcture ia not In�endetl or olieretl br sele(Sec.7044,Buslnese entl Pmfes- �
slons Cotle: The Cantreclor'S Licenae Lew tloes not apply to an owner of property who bulitls or WOOD SHINGLES ��\ �
Impmvee thereon,entl who tloea euc�work hlmneli or��rouph his own em0loyeea,p�ovltlatl�hal �
such Improvements are nol inlentlatl ar offareE lor eela.II.�owever,t�e bullEing or improvemenl
Iseoltlw�ihlnoneyeerolcomple�lon,Iheownao-bullderwillhavetheburGenofprovinglhethetlitl OTHER(SPECIFY) �
not builtl or Improve lor purpose al aaleJ. '
❑I,ee owner ol t�e pmperry,em excluelvely conhec�ing with licanaed conVaclore�o cone�mc�
tha pmlect(Sec.]004,Businasa entl Pm�esslone Cotle:The Conveclore Lleensa Lew Ooes not PROVIDE I.C..B.�.REPORT NO.
epPIY to en owner ol propery who OWltla or Impmvee iheraon,antl w�o conVeds tor euch pmjects
with e contrector(s)Ilcaneetl pureuent io tha Conhactore Ucenea Lew. PR�V��E MFGR. �N$TA�LAT�ON$PEC$.
❑I em exampt untler Sec. ,B B P.G lor ihla reeson
o.�e� oe�e APPLICATION DATE VALUATION PERMIT FEE
WORNER'S COMPENSATION DECLARATION
1 hereEy elfirm under penelry ol per�ury one of ihe following tleclaratlon: g/Q� .
❑I heve entl wlll melnteln e Certlilcete ol Conaent to aelbinsure forWorker's Compensatlon. � Buildin
ea pmvitletl lor Cy Sectlon 3'100 of the Labor COEe,for the petlormence ol Ihe work lor which thle
permil ia lssued. � � $81Sf1'11C �e �
�p(��ava end wlll malntein Warkefe Compeneelion Inaurance,as reqWretl by Sactlon 3]00 0l
„th�C30or Cotle,br the peMormenca ol�he work�or whlth�hle perml�le IssuaG.My Work r's � � /oT
Compen � n Ins rance carrler entl Pollcy n mber ere: I � TOfdl
cerde�IL �A..YI� POI1cy No. •�� � PERMIT AUTHORIZATION DATE
- CERTIFICATE OG EXEMPTION FqOM WORKER$'
COMPENSATION INSURANCE N.G�] /
(Thle aeclion neetl not ba completad il iha parmit ia tar one huntlretl tlollare($100)or IeeaJ �� � / .�(�.-.C� O
I certlfy ihat in the peAormance of Iha vrork tor which this permit Is Iseuea,I shall not employ ^ �•� �
eny pereon In eny manner eo ea to Gecome su0�ect to Iha Workera'Compensetlon Lewe af Cell- AII(OOf.^.shall be inspected prlor to any roofing material being
�0f"'a installed. If a roof is installed without first obtaining an
oaie Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,aflar making thle Certilicele al Exampllon,you nhould Eecoma
aubjacttothaWorkere'CompeneatlonOrovlsionaollheLeborCotle,youmustfort�wllhcomply Applicant understands and will comply with all non point
with auch provisions or t�le permit e�elCbe aeamad revoked. SOU fC8 fB9U�3�lOf1S.
I certl�ythet I have reetl ihie eppllcetlon entl emta ihat mo nbove Inlorma�lon ie torrect I eBree ' I
mcomPiywunenmya�a�o��ryomma�=aaeoae�a�aia.a,oia�ma�oe�uameco�av��non,aoe Allroofcoveringstobeclass" orbetter.
�eretiy euthotlze representativae ol�hle city to enler upon the abave�menllonetl pmperry br In� � � �
epeIXlon purposes.
(We)epma m eeve,InEemnlly antl keep hermlese the Clly ol Cupertlno egeinst Ilebilitiea,
�utlgmenta,costa end expensea whlch mey In any wey accrua pgeinet eeltl City in coneequence
o�ma grannng m tnie perm�c SIGNAT P LIC T ATE
. PRE-INSPECTION: PLVWOOD: . � IN-PROGR �
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 �