R-5405 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5405
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN left DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
IO 7' 2 RESIDENTIl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes–1 understand that a Class A
NAME Niroof assembly is required
Iniiial LC.B.O.a
ADDRESS-M Z-4 SaJA II y N E J)lI EXISTING ROOF COVERING
PHONE _. V NUMBER OF EXISTING COVERINGS '
CONTRACTO 'S
n � ,cl-i ' TO BE REMOVED TO BE RETAINED
NAME
ADDRESS�r l> 'Z^1 l ' �A n.A,l•C1� C/� �7�XISTING .TMPE OF ROOF COVERING
aTvszlP 0
PHONE 7'7�/ / L7 �� BUILT-UP ROOF
LICENSE // 9p��
NUMBER l0 Z ASPHALT SHINGLES C/)}• ❑
LICENSED CONTRACTORS DECLARATION U�,
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
effect.
nL, WOOD SHINGLES E]
License �-� -J Lic.Number `
Dole v' / Contractor G OTHER(SPECIFY)
- OWNER-BUILDER DECLARATION PROPOSED
1 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
con applicant,alter,improve,to filsigned statement
em enthatstructure,Is license issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file demolish,signed statement that he Is licensed it tl pursuant al the quire the
of the Contractor's License Law(Chapter B(commencing with Section 700()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
a civil penalty of not more than five hundred dollars($500).):
C]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 Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,antl who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement 1 Cl
Is Sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑ i.Yv J`f� ,
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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sac. ,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:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. G Q/�
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 /-I 1 Seismic
,the Labor Code for the performance of the work for which this permit is issued.My Workers I
Consume T1 aur ncecerrlerao(<Poll no bar are: 13 7
Total
Carrier Policy No. PERMIT AUTHORI TION - D
CERTI:1 ATE OF EXEMPTION FROM WORKERS' ow
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hu red tlolISIS(5100)or less.)
ce01ty that In the performance of the work for which Is p It Is issued, shall not employ
any person In any manner so as to become subject to a he an ran Law of n- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date�,L�—� Applicant inspection,I agree to remove all new materials for inspection.
subject too Eh Workers'CompensationPL CANT: 1provisions f1i LaborrC Exemption,
em you must forthwitthbcomply Applicant Ljnderstands and Will Comply with all non point
with such provisions or this permit shelf;be deemed revoked. source reatlonS.
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 ening C"or better.
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, Z /
judgments,costs and expenses which may In any way accrue against said City In consequence E APPLIC T DATE
• of the granting of this permit,
PRE-INSPECTION: PLYWOOD: VIN-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