R-5280 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB RR- 5280
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 LAST CALLED INSPECTION.
BUILDING ADDRESS //�� /
-I O ✓ (vA > RESIDENTIAL COMMERCIAL OTHER
OWN 's - HAZARDOUS FIRE AREA
NA `�/ YES ❑ If yes—I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS �(� EXISTING ROOF COVERING
PHONE- l ' _�_ ' 71131 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S ^^ '/1�
NAME Ws , \OO I TO BE REMOVED TO BE RETAINED
ADDRESS _ TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE 'l-l� �C� ( � BUILT-UP ROOF ❑
LICENSE ASPHALT SHINQLES 4 /® C]NUMBER yJ
LICENSED CONTRACTORS DECLARATION %
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SH�,f�ES ) g ^_ ❑
]000)of Dlvislon 3 of the Business and Professions Code,and my license Is In lull force and ��YY -N4L'p�
affect ((}} 6
((//�� WOOD SHINGLE9!^(/p,,. ❑
License CIOL Lip.Number Cy
, OTHER(SPECIFY) TEND ❑
Date� {.,q_Contractor
�` dptfrom-BUILDER DE Contractors
License
PROPOSED
1 hereby affirm Bu that am exempt from the e: Any
License Lew for the following reeaon.
(Sec.7031.8,r,improve,
and Profedemolish,
or re Code: Any city or county which requires also a permit to ,
construct,alter,Improve,demolish,or repeat any structure,prior to Its Issuance,also reproves the BUILT-UP ROOF
or the
for such pecan to file a signed statement that he it licensedactio pursuant a to the provisionsothb
' of the Contrectofe License Lew(Chapter h is ex(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the bawls for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to C/
e civil penalty of not more than live hundred dollars(h wag): WOOD SHAKES Y�
❑I,ea owner ofthe property,t i to ded employees with wages as their Bole Compensetlon,wolf s.
the work,and the structure Is not intended ores hottl for safe(Sea owner
of Business and builds
Or
sions improves
Contractor's License Law tli sea or throapply ugh hisO n employers,who idedsor WOOD SHINGLES ❑
Improves thereon,and who does n such work himself or through Ne awn employees,provided that
such Improvements aro not completion,
leb n,or offered for edea.ill however,the en of pr or Improvement
Is sold not
or
year of for purpose
stheowner-bulltlerwill have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑1,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 8 P.C.for this reason
owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
x I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a of the caro of Consent to self-insure for Worker's Compensation, I v l
permit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which this ^ Building`
permit la Issued. I
❑I have and will maintain Worker's Compensation Insurance,as required is I by Section Worker's of BISRIIC
z the Laser Code,for the performance of the irk for which this permit is Issued.My Worker's
Campo�°�-o�—In]s�r n�carrlar ntl Policy n bar are; -5 Total
carrier -]1 w�� Policy Nd ' I PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N00)o '
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for which this permit Is issued shall not employ
any person in any manner so as to become subject to the Worker, imp ffrwuan Laws of Call- All roofs shall be inspected prior to any roofing material being
rornaa. r installed. If a roof is installed without first obtaining an
odta�^, Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: If,after making this Certificate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP understands and WIII 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 state laws relating to building construction,and All roof coverings to blass' or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In.
epection purposes.
(We)agree to save,pe Indemnify w end keep harmless nyythe City of Cupertino against Ilebllllles,
. judgments,iasis and permit.
which may on any way accrue against said Cly In consequence
ohne granting of this permu. SIGNA URE OF APPLICANT 'DAT
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