R 5200 PERMIT R_ 5200
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
I9ao ,S4i V rT RESIDENTIAL COMMERCIAL OTHER
OWNER'S C` HAZARDOUS FIRE AREA
�11 jfT c YES ❑ If yes—I understand that a Class A
NAME '/I'C.✓ `J•�ry'T aesembly is required.
NO Initial I.C.B.O.7F
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT�'R'k64,� jt/�,7[rr� J�j /n/I�
NAME ` --1�LYll.1/r 1 r":a TO BE REMOVED�TO BE RETAINED
ADDRESS ( /' ' S TYPE OF ROOF COVERING
CITY&ZIP �•v!I{IJ1 Q'7 I✓ ,7I CJ l EXISTING
Z
PHONE- ,v�U/ �/� BUILT-UP ROOF ❑ .
LICENSE
NUMBER �—.(/_47/,a•�
XJ �J ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of OI ISIon 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Cleee �� LIC.Number
Data contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION ' PROPOSED
hereby affirm that I am exempt from Professions the e: Anytars License Lew for the uir $a mall 1.
(Sec.7031.5,r,Impr ve end olish,ofreCode: Any cry or county which requires a permit to
construct,pplicantaltar,Improve,10 file demolish, ny thate,prior!nitslssuance,pursuant to the
sthe BUILT-UP ROOF /
applicant for such permit to Ilia asignedsmtememmetla Is licensed ctio 7000)of tothe provisions the
• of the ss an Professions
License Law(Chapter a Is ex encinp with Section 7000)of Division 3 of the
ex
Business end violation of Code)or that he le exempt therefrom and the bash for the scant to ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section 7031,5 by any applicant for a permit subjects the applicant to
e civil penalty of not mora then five hundred dollars($500).): '
01,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(See.7044,Business and Proles.
' alone Cow:The Contractors Ucense Law does not apply to an owner of properly,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.It,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.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Proteealona Code:The Contractors 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.
❑ P. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B& C.for 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, / n
permit Is Is for by Section 3700 of the Labor Code,for the performance of the work br,whlchthis IOr1�-y/ *3 Building
4 permit le Issued. JP
), +UG g/j SBISRIIC
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700 0l Ir _
the Labor Cotle,for the Detormand of the work for which this permit Is issued.My Workers rJrT T)=CO
Compensation Insurance carrier entl Policy number are: - Total
e Carrier Policy No. RM A RIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p �/ r' -
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.) . 'Cl l s OE: G /0.
certify that In the performance of the coo for which ihla permit is leeye shall not employ
any person In any manner so as to become su ct to the Workers'Co pane�lnn Lowe m can- All roofs shaWbe inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
X Data + Applicant t� '1' V inspection,I agree to remove all new materials for inspection.
subject to Ens WTO mkamCCompensation proviafter sionls ofethelcate of Labor Code,you must forthwitbecome
h comply Applicant understands and will 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 some Information la correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,andZURE
ZQF
e lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
eP(WeIl purposes. / �_/ rj�
(We)puree to save,Indemnity and keep harmless the City of Cupertino epelnat Ilebllltlae,judgmenti,coats and expenses which may In any way accrue against said CIN IWconseDuence
of K granting of this permr. ICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY