R-5235 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5 2 3 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1Be DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
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BUILDING ADDRESS
I � RESIDENTIAl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
-. YES ❑ II yes—I understantl that ti Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.b
ADDRESS EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS
CONTRR'
TO BE REMOVED - TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
�. (k-� EXISTING
PHONE BUILT-UP ROOF
LICENSE i
NUMBER12�1t�141i ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Jpslness and Professions Code,and my license Is in full force and
effect. /�\11
WOOD SHINGLES ❑
License ca Lic.Number
OTHER(SPECIFY) ❑
DatContractor s ��
NER-BUILDERD a ATIDN ROPOSED
hereb affirm that a exempt from the Contractor's License Lew for the following reason.
(Sec.70 1.5,Business and Professions Code: Any city or county which requires a permit to p� p B
conslrucq alter,Improve,demolish,or repair any structure,prlorto Its issuance,also requires the BUILT-UP ROOF P N
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
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of the Contractor's License Law(Chapter 9(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
10 exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to JUN 24 901
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ry rI
_
❑1,as owner of the property,or my employees with wages Be their sole compensation,will do CITY I Ur LUr�rui
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and ProfesI 114U
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sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES' Elimproves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or Chaired for sale.If,however,the building or improvement
Is..to 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 Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bu lids 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 Sec. ,B&P.C.far this reason
Owner nate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
'
711 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, ^ Bulldln�
as or f
provided by Section 3700 of the Labor Code,for the performance of the work fair which this
permit Is Issued. ,`f^f I U
El I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ISmic
the Labor Cade,for the performance of the we for which this permit is Issued.My Worker's 41
,the
saran c rler Policy num r ere:'.'5D nom- Total
Caryl Policy No. �-�✓I PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars(5100)or less.) Ice?
I Certify that in the performance of the work for which this permit Is issuetl, shell not employ
any person in any manner so as to become subject to the Workers'Ggqipenpti n Lews of Celi- All roofs shall be inspected prior to any roofing material being
for" installed. If a roof is installed without first obtaining an
DatPllpanl :MA inspection,I agree to remove all new materials for inspection.
shoulecome
subjeot to h2W, fix
s' ompeAPPLI NT: lnsatlon proivisionts of the lLaborCode,you mustufo thwitlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit an 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 ty be S`C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in- ^�
spection purposes. t L
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit. .
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